Healthcare Provider Details

I. General information

NPI: 1861191603
Provider Name (Legal Business Name): MATHEW JOHNSON PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2023
Last Update Date: 03/01/2023
Certification Date: 03/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 MORRIS ST
CHARLESTON WV
25301-1326
US

IV. Provider business mailing address

326 ROXALANA HILLS DR
DUNBAR WV
25064-1922
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-3417
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835C0205X
TaxonomyCritical Care Pharmacist
License NumberRP0010759
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: