Provider Demographics
NPI:1528360518
Name:JOHNSON, KENT GOULDING (RPH)
Entity Type:Individual
Prefix:MR
First Name:KENT
Middle Name:GOULDING
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 KESTREL CT
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-2777
Mailing Address - Country:US
Mailing Address - Phone:719-275-7739
Mailing Address - Fax:
Practice Address - Street 1:1414 MAIN ST
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-3906
Practice Address - Country:US
Practice Address - Phone:719-275-5221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-23
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10006183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist