Provider Demographics
NPI:1629454897
Name:JOHNSON, JERRY (RPH)
Entity Type:Individual
Prefix:
First Name:JERRY
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 1:4004 LAKE ADGER PKWY
Mailing Address - Street 2:
Mailing Address - City:MILL SPRING
Mailing Address - State:NC
Mailing Address - Zip Code:28756-4800
Mailing Address - Country:US
Mailing Address - Phone:828-899-8974
Mailing Address - Fax:828-894-8975
Practice Address - Street 1:4004 LAKE ADGER PKWY
Practice Address - Street 2:
Practice Address - City:MILL SPRING
Practice Address - State:NC
Practice Address - Zip Code:28756-4800
Practice Address - Country:US
Practice Address - Phone:828-899-8974
Practice Address - Fax:828-894-8975
Is Sole Proprietor?:No
Enumeration Date:2015-08-10
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9508183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC420605OtherNABP