Provider Demographics
NPI:1790073344
Name:JOHNSON, MATTHEW (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
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 1:928 GOLD HILL RD
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708-7947
Mailing Address - Country:US
Mailing Address - Phone:803-548-7197
Mailing Address - Fax:
Practice Address - Street 1:928 GOLD HILL RD
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708-7947
Practice Address - Country:US
Practice Address - Phone:803-548-7197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-18
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21976183500000X
SC13382183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC21976OtherSTATE LICENSE NUMBER
SCPH-13382OtherSTATE LICENSE NUMBER