Provider Demographics
NPI:1891166351
Name:JOHNSON, MATTHEW TYLER (PHARMD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:TYLER
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 1:1366 N GARDNER ST
Mailing Address - Street 2:P.O. BOX 346
Mailing Address - City:SCOTTSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47170-7793
Mailing Address - Country:US
Mailing Address - Phone:812-752-4226
Mailing Address - Fax:812-752-4056
Practice Address - Street 1:1366 N GARDNER ST
Practice Address - Street 2:
Practice Address - City:SCOTTSBURG
Practice Address - State:IN
Practice Address - Zip Code:47170-7793
Practice Address - Country:US
Practice Address - Phone:812-752-4226
Practice Address - Fax:812-752-4056
Is Sole Proprietor?:No
Enumeration Date:2015-10-09
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26025460A183500000X
KY016971183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist