Provider Demographics
NPI:1710582754
Name:JOHNSON, AMY CAROLINE (PHARMD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:CAROLINE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 HOUSTON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102-3933
Mailing Address - Country:US
Mailing Address - Phone:817-820-0488
Mailing Address - Fax:817-776-4102
Practice Address - Street 1:515 HOUSTON ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-3933
Practice Address - Country:US
Practice Address - Phone:817-820-0488
Practice Address - Fax:817-776-4102
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX610321835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX61032OtherTX STATE BOARD OF PHARMACY LICENSE