Provider Demographics
NPI:1497340236
Name:JOHNSON, PATRICE LANAE (RPH, PMP)
Entity Type:Individual
Prefix:
First Name:PATRICE
Middle Name:LANAE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RPH, PMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13601 KENTON AVE
Mailing Address - Street 2:
Mailing Address - City:CRESTWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60418-1938
Mailing Address - Country:US
Mailing Address - Phone:708-926-7270
Mailing Address - Fax:855-793-8197
Practice Address - Street 1:13601 KENTON AVE
Practice Address - Street 2:
Practice Address - City:CRESTWOOD
Practice Address - State:IL
Practice Address - Zip Code:60418-1938
Practice Address - Country:US
Practice Address - Phone:708-926-7270
Practice Address - Fax:855-793-8197
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-03
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-039374183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist