Provider Demographics
NPI:1710984588
Name:JOHNSON, BRADLEY THIREN (RPH,CGP,CDM)
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:THIREN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:RPH,CGP,CDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 LORELLA AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-7823
Mailing Address - Country:US
Mailing Address - Phone:541-343-7162
Mailing Address - Fax:541-242-8303
Practice Address - Street 1:4010 AERIAL WAY
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97402-9757
Practice Address - Country:US
Practice Address - Phone:541-242-8525
Practice Address - Fax:541-242-8520
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6258183500000X
ORHD0321311835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered183500000XPharmacy Service ProvidersPharmacist
Not Answered1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0759OtherGERIATRIC CERTIFICATION
OR6258OtherPHARMACY LISCENSE
ORHD032131OtherDIABETES MANAGMENT CERTIF