Provider Demographics
NPI:1982207767
Name:JOHNSTON, JASON BRADFORD
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:BRADFORD
Last Name:JOHNSTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6000 NW 2ND ST STE 200A
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73127-6515
Mailing Address - Country:US
Mailing Address - Phone:405-787-3939
Mailing Address - Fax:405-787-3959
Practice Address - Street 1:6000 NW 2ND ST STE 200A
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73127-6515
Practice Address - Country:US
Practice Address - Phone:405-787-3939
Practice Address - Fax:405-787-3959
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12858183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist