Provider Demographics
NPI:1912372806
Name:JOHNSON, COLLEEN (PHARMD)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
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 1:4125 AUSTELL RD
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-1836
Mailing Address - Country:US
Mailing Address - Phone:678-945-4530
Mailing Address - Fax:
Practice Address - Street 1:4125 AUSTELL RD
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1836
Practice Address - Country:US
Practice Address - Phone:678-945-4530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-03
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH027621183500000X
FLPS51213183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist