Provider Demographics
NPI:1619298296
Name:JOHNSON, GENE O (RPH)
Entity Type:Individual
Prefix:
First Name:GENE
Middle Name:O
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 1:603 SW BAKER ST.
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-9168
Mailing Address - Country:US
Mailing Address - Phone:503-474-3795
Mailing Address - Fax:503-474-3582
Practice Address - Street 1:603 SE BAKER ST
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-6429
Practice Address - Country:US
Practice Address - Phone:503-474-3795
Practice Address - Fax:503-474-3582
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-17
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5943183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist