Provider Demographics
NPI:1740729128
Name:JOHNSON, NADINE (RPH)
Entity type:Individual
Prefix:
First Name:NADINE
Middle Name:
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 1:4120 SAINT PAUL BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14617-2351
Mailing Address - Country:US
Mailing Address - Phone:203-768-8413
Mailing Address - Fax:
Practice Address - Street 1:23 SLAYTON AVE
Practice Address - Street 2:
Practice Address - City:SPENCERPORT
Practice Address - State:NY
Practice Address - Zip Code:14559-1427
Practice Address - Country:US
Practice Address - Phone:585-352-4020
Practice Address - Fax:585-352-4385
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-17
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYI-039375183500000X
CT08132183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist