Healthcare Provider Details

I. General information

NPI: 1639250426
Provider Name (Legal Business Name): HERBERT DALE JOHNSON BS, RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 TRILLIUM WAY
CORBIN KY
40701-8426
US

IV. Provider business mailing address

1218 OAK RIDGE RD
CORBIN KY
40701-6294
US

V. Phone/Fax

Practice location:
  • Phone: 606-528-1212
  • Fax: 606-526-8338
Mailing address:
  • Phone: 606-528-5943
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number8024
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: