=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174515746
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GINA RYAN JOHNSON PHARM.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4468 LYNGATE DR SW
-----------------------------------------------------
City | LILBURN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30047-8962
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-923-6481
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3001 MERCER UNIVERSITY DR
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30341-4115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-547-6222
-----------------------------------------------------
Fax | 678-547-6384
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1835P1200X
-----------------------------------------------------
Taxonomy Name | Pharmacotherapy Pharmacist
-----------------------------------------------------
License Number | 018819
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------