Provider Demographics
NPI:1477043545
Name:JOHNSON, DEREK CHARLES
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:CHARLES
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 1:1000 WORTHINGTON LN APT 26207
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:TN
Mailing Address - Zip Code:37174-3069
Mailing Address - Country:US
Mailing Address - Phone:701-367-9937
Mailing Address - Fax:
Practice Address - Street 1:3600 MALLORY LN
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37067-2900
Practice Address - Country:US
Practice Address - Phone:615-771-0391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-15
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN118674183500000X
SDR5689183500000X
TN0000041475183500000X
NDRPH4896183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist