Provider Demographics
NPI:1013299320
Name:JOHNSON, KIMBERLY SHANELLE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:SHANELLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5108 NORWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32208-5032
Mailing Address - Country:US
Mailing Address - Phone:904-768-4491
Mailing Address - Fax:904-764-4706
Practice Address - Street 1:5108 NORWOOD AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32208-5032
Practice Address - Country:US
Practice Address - Phone:904-768-4491
Practice Address - Fax:904-764-4706
Is Sole Proprietor?:No
Enumeration Date:2011-09-13
Last Update Date:2022-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS0029492183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist