Provider Demographics
NPI:1174712715
Name:JOHNSON, KENNETH WAYNE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:WAYNE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 PAWNEE DR
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-5245
Mailing Address - Country:US
Mailing Address - Phone:812-288-7767
Mailing Address - Fax:
Practice Address - Street 1:1850 BLUEGRASS AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215-1161
Practice Address - Country:US
Practice Address - Phone:502-361-6015
Practice Address - Fax:502-361-6529
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-19
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26014524A183500000X
KY008527183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist