Provider Demographics
NPI:1760140065
Name:JOHNSON, KYLE (PHARMD)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
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 1:35401 MISSION DR
Mailing Address - Street 2:
Mailing Address - City:ST IGNATIUS
Mailing Address - State:MT
Mailing Address - Zip Code:59865-7791
Mailing Address - Country:US
Mailing Address - Phone:406-745-2426
Mailing Address - Fax:
Practice Address - Street 1:35401 MISSION DR
Practice Address - Street 2:
Practice Address - City:ST IGNATIUS
Practice Address - State:MT
Practice Address - Zip Code:59865-7791
Practice Address - Country:US
Practice Address - Phone:406-745-2426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-03
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPHA-PHA-LIC-695773336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy