Provider Demographics
NPI:1780197640
Name:JOHNSON, KIM (RPH)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:465 SHENKS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:CONESTOGA
Mailing Address - State:PA
Mailing Address - Zip Code:17516-9781
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:555 N DUKE ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17602-2250
Practice Address - Country:US
Practice Address - Phone:717-544-5929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-14
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP044012L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist