Provider Demographics
NPI:1497472922
Name:DOTY, JOHNATHAN
Entity Type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:
Last Name:DOTY
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 1:4218 LINDELL BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-2916
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4218 LINDELL BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2916
Practice Address - Country:US
Practice Address - Phone:314-371-4286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-25
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022042508183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist