Provider Demographics
NPI:1942372883
Name:JOHNSON, ROBERT EARL (RPH)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:EARL
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 1:1058 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FORTUNA
Mailing Address - State:CA
Mailing Address - Zip Code:95540-2009
Mailing Address - Country:US
Mailing Address - Phone:707-725-4431
Mailing Address - Fax:707-725-2671
Practice Address - Street 1:1058 MAIN ST
Practice Address - Street 2:
Practice Address - City:FORTUNA
Practice Address - State:CA
Practice Address - Zip Code:95540-2009
Practice Address - Country:US
Practice Address - Phone:707-725-4431
Practice Address - Fax:707-725-2671
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA035667183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0544735OtherNCPDP
CAPHA372680Medicaid
0810750001Medicare ID - Type Unspecified