Provider Demographics
NPI:1922128099
Name:JOHNSON, DOUGLAS TODD (RPH)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:TODD
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MULLINS
Mailing Address - State:SC
Mailing Address - Zip Code:29574-3112
Mailing Address - Country:US
Mailing Address - Phone:843-464-1757
Mailing Address - Fax:843-464-1751
Practice Address - Street 1:310 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MULLINS
Practice Address - State:SC
Practice Address - Zip Code:29574-3112
Practice Address - Country:US
Practice Address - Phone:843-464-1757
Practice Address - Fax:843-464-1751
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC008245183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC008245OtherRPH LICENSE