Healthcare Provider Details

I. General information

NPI: 1275461337
Provider Name (Legal Business Name): GRANT JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 ALBERTSON PKWY
BROUSSARD LA
70518-4347
US

IV. Provider business mailing address

1400 S MORGAN AVE
BROUSSARD LA
70518-5123
US

V. Phone/Fax

Practice location:
  • Phone: 337-839-1717
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPNT.049996
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: