Provider Demographics
NPI:1467993063
Name:JOHNSON, ERIC
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6165 WILTSHIRE CT
Mailing Address - Street 2:
Mailing Address - City:LIBERTY TOWNSHIP
Mailing Address - State:OH
Mailing Address - Zip Code:45044-7587
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4966 GLENWAY AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45238-3905
Practice Address - Country:US
Practice Address - Phone:513-337-9995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-15
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03118844183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist