Healthcare Provider Details

I. General information

NPI: 1710544010
Provider Name (Legal Business Name): JACKIE PAIGE JOHNSTON PHARMD, BCPS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2019
Last Update Date: 05/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 PARK ST
NEW HAVEN CT
06511-5474
US

IV. Provider business mailing address

529 JEFFERSON ST APT 5
HOBOKEN NJ
07030-2013
US

V. Phone/Fax

Practice location:
  • Phone: 203-558-0675
  • Fax:
Mailing address:
  • Phone: 203-558-0675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835C0205X
TaxonomyCritical Care Pharmacist
License Number28RI03875000
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code1835C0205X
TaxonomyCritical Care Pharmacist
License NumberPCT.0013301
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: