Provider Demographics
NPI:1770183295
Name:JOHNSON, KRISTEN NICHOLE
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:NICHOLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:NICHOLE
Other - Last Name:HOPKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1516 N 18TH ST
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:AR
Mailing Address - Zip Code:72949-3611
Mailing Address - Country:US
Mailing Address - Phone:479-667-4448
Mailing Address - Fax:
Practice Address - Street 1:1516 N 18TH ST
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:AR
Practice Address - Zip Code:72949-3611
Practice Address - Country:US
Practice Address - Phone:479-667-4448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD14066183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist