Provider Demographics
NPI:1104260595
Name:JOHNSON, SCOTT C (PHARMD,)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:C
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PHARMD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 E 600 N
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-5772
Mailing Address - Country:US
Mailing Address - Phone:208-604-4238
Mailing Address - Fax:
Practice Address - Street 1:1295 PARKWAY DR
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-1683
Practice Address - Country:US
Practice Address - Phone:208-785-1311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-29
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP6540183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist