Provider Demographics
NPI:1578981262
Name:JOHNSON, LARRY (PHARMD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18928 AUBERRY RD
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93619-9641
Mailing Address - Country:US
Mailing Address - Phone:559-908-0189
Mailing Address - Fax:
Practice Address - Street 1:18928 AUBERRY RD
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93619-9641
Practice Address - Country:US
Practice Address - Phone:559-908-0189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-31
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28426183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA28426OtherPHARMACY LICENSE