Provider Demographics
NPI:1598009938
Name:JOHNSON, MARK R
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:JOHNSON
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 1:273 12TH ST NE
Mailing Address - Street 2:UNIT 313
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-3853
Mailing Address - Country:US
Mailing Address - Phone:985-788-4598
Mailing Address - Fax:
Practice Address - Street 1:273 12TH ST NE
Practice Address - Street 2:UNIT 313
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-3853
Practice Address - Country:US
Practice Address - Phone:985-788-4598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13210183500000X
AL14338183500000X
MS010668183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist