Provider Demographics
NPI:1609579168
Name:JOHNSON, BLAKE (RPH)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
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 1:8979 NE TENNYSON ST APT 316
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97006-2927
Mailing Address - Country:US
Mailing Address - Phone:760-672-9986
Mailing Address - Fax:
Practice Address - Street 1:8979 NE TENNYSON ST APT 316
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97006-2927
Practice Address - Country:US
Practice Address - Phone:760-672-9986
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-23
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0019356183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist