Provider Demographics
NPI:1639724842
Name:JOHNSON, GARY W (RPH)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:W
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:PO BOX 185
Mailing Address - Street 2:
Mailing Address - City:DALHART
Mailing Address - State:TX
Mailing Address - Zip Code:79022-0185
Mailing Address - Country:US
Mailing Address - Phone:806-717-9416
Mailing Address - Fax:806-249-9717
Practice Address - Street 1:1601 TENNESSEE AVE
Practice Address - Street 2:
Practice Address - City:DALHART
Practice Address - State:TX
Practice Address - Zip Code:79022-5110
Practice Address - Country:US
Practice Address - Phone:806-249-4772
Practice Address - Fax:806-249-9717
Is Sole Proprietor?:No
Enumeration Date:2019-08-05
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20777183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist