Provider Demographics
NPI:1891078614
Name:JOHNSON, MATTHEW TODD (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:TODD
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 1:210 STATE HIGHWAY 165
Mailing Address - Street 2:
Mailing Address - City:BRANSON
Mailing Address - State:MO
Mailing Address - Zip Code:65616-3464
Mailing Address - Country:US
Mailing Address - Phone:417-339-3996
Mailing Address - Fax:
Practice Address - Street 1:210 STATE HIGHWAY 165
Practice Address - Street 2:
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-3464
Practice Address - Country:US
Practice Address - Phone:417-339-3996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007021852183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOT175199001OtherDRIVER LICENSE NUMBER
MO2007021852OtherSTATE LICENSE NUMBER