Provider Demographics
NPI:1568986917
Name:JOHNSON, KELLY OWENS (PHARMD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:OWENS
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 STONEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29649-9709
Mailing Address - Country:US
Mailing Address - Phone:803-240-8131
Mailing Address - Fax:
Practice Address - Street 1:479 BYPASS 72 NW STE 100
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29649-1484
Practice Address - Country:US
Practice Address - Phone:864-223-8909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-27
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC372333336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy