Provider Demographics
NPI:1750600136
Name:JOHNSON, VANESSA KAY
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:KAY
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 UPPER RIVER RD
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1836
Mailing Address - Country:US
Mailing Address - Phone:740-446-8366
Mailing Address - Fax:740-446-7497
Practice Address - Street 1:185 UPPER RIVER RD
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-1836
Practice Address - Country:US
Practice Address - Phone:740-446-8366
Practice Address - Fax:740-446-7497
Is Sole Proprietor?:No
Enumeration Date:2010-05-24
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03326647183500000X
WVRP0006818183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist