Provider Demographics
NPI:1811582596
Name:JOHNSON, AMANDA G (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:G
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 HIGHWAY 51
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-9088
Mailing Address - Country:US
Mailing Address - Phone:601-853-2088
Mailing Address - Fax:
Practice Address - Street 1:1100 HIGHWAY 51
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-9088
Practice Address - Country:US
Practice Address - Phone:601-853-2088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-04
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE010799183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist