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General NPI Number Information
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NPI Number | 1912128513
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Entity Type | Individual
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Provider Name | RYAN TERRY JOHANSEN
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Gender | Male
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Dates
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Enumeration Date | 05/01/2007
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Last Update Date | 07/28/2022
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Provider Practice Location Address
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Address Line | 3179 N CANYON RD
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City | PROVO
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State | UT
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Zip | 84604-3916
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Country | US
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Telephone | 801-377-2002
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Fax | 801-377-2007
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Provider Business Mailing Address
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Address Line | 3638 W 12125 S
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City | RIVERTON
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State | UT
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Zip | 84065-7404
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Country | US
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Telephone | 801-440-2995
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 336415-1701
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License Number State | UT
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