Provider Demographics
NPI:1750635728
Name:JOHNSON, MATTHEW HEWLETT (PHARMD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:HEWLETT
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2635 NE LOOP 410
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78217-5608
Mailing Address - Country:US
Mailing Address - Phone:215-833-2164
Mailing Address - Fax:
Practice Address - Street 1:12400 HIGH BLUFF DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-3077
Practice Address - Country:US
Practice Address - Phone:866-353-6685
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-30
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX48491183500000X
PA442483183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist