Provider Demographics
NPI:1730654641
Name:JOHNSON, AMBER R (PHARMD)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:R
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 1:2811 CORY CT SW APT 7
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52404-4030
Mailing Address - Country:US
Mailing Address - Phone:601-503-7765
Mailing Address - Fax:
Practice Address - Street 1:2811 CORY CT SW APT 7
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52404-4030
Practice Address - Country:US
Practice Address - Phone:601-503-7765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-06
Last Update Date:2018-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA23466183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA23466Medicaid