Provider Demographics
NPI:1639250426
Name:JOHNSON, HERBERT DALE (BS, RPH)
Entity Type:Individual
Prefix:MR
First Name:HERBERT
Middle Name:DALE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:BS, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1218 OAK RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40701-6294
Mailing Address - Country:US
Mailing Address - Phone:606-528-5943
Mailing Address - Fax:
Practice Address - Street 1:1 TRILLIUM WAY
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-8426
Practice Address - Country:US
Practice Address - Phone:606-528-1212
Practice Address - Fax:606-526-8338
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY8024183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist