Provider Demographics
NPI:1538123955
Name:JOHNSON, MICHAEL KENNETH (RPH)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:KENNETH
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 1:101 CHARWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24210-2576
Mailing Address - Country:US
Mailing Address - Phone:276-676-2900
Mailing Address - Fax:276-676-2915
Practice Address - Street 1:101 CHARWOOD DR
Practice Address - Street 2:
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24210-2576
Practice Address - Country:US
Practice Address - Phone:276-676-2900
Practice Address - Fax:276-676-2915
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202011066183500000X
FLPS29942183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4835154OtherNCPDP