Healthcare Provider Details

I. General information

NPI: 1588385157
Provider Name (Legal Business Name): REBAKKAH JERREAH JOHNSON PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2022
Last Update Date: 09/12/2022
Certification Date: 09/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ROYAL HEIGHTS CTR
BELLEVILLE IL
62226-5705
US

IV. Provider business mailing address

1935 RAFT DR
SAINT LOUIS MO
63133-1151
US

V. Phone/Fax

Practice location:
  • Phone: 618-233-0100
  • Fax: 618-641-9801
Mailing address:
  • Phone: 314-803-5798
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.302932
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: