Provider Demographics
NPI:1912128513
Name:JOHANSEN, RYAN TERRY
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:TERRY
Last Name:JOHANSEN
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 1:3638 W 12125 S
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065-7404
Mailing Address - Country:US
Mailing Address - Phone:801-440-2995
Mailing Address - Fax:
Practice Address - Street 1:3179 N CANYON RD
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3916
Practice Address - Country:US
Practice Address - Phone:801-377-2002
Practice Address - Fax:801-377-2007
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT336415-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist