Healthcare Provider Details

I. General information

NPI: 1215041298
Provider Name (Legal Business Name): KELLEY R JOHNSON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 01/18/2022
Certification Date: 01/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1743 N FRASER ST
GEORGETOWN SC
29440-6407
US

IV. Provider business mailing address

1743 N FRASER ST
GEORGETOWN SC
29440-6407
US

V. Phone/Fax

Practice location:
  • Phone: 843-546-2222
  • Fax: 843-527-8300
Mailing address:
  • Phone: 843-546-2222
  • Fax: 843-527-8300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2164
License Number StateSC

VIII. Authorized Official

Name: KELLEY RAY JOHNSON
Title or Position: OWNER
Credential: RPH
Phone: 843-546-2222