Provider Demographics
NPI:1962081265
Name:JOHNSON, LARRY DEWAYNE (RPH)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:DEWAYNE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9921 LINDEN LEA RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:TX
Mailing Address - Zip Code:75762-6704
Mailing Address - Country:US
Mailing Address - Phone:903-312-1058
Mailing Address - Fax:
Practice Address - Street 1:104 W HENDERSON ST
Practice Address - Street 2:
Practice Address - City:OVERTON
Practice Address - State:TX
Practice Address - Zip Code:75684-1613
Practice Address - Country:US
Practice Address - Phone:903-834-0154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-05
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30241183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist