Provider Demographics
NPI:1154615433
Name:JOHNSON, KELLY GILMER
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:GILMER
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 W. HWY 74
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28110
Mailing Address - Country:US
Mailing Address - Phone:704-282-1445
Mailing Address - Fax:704-290-1035
Practice Address - Street 1:2901 W. HWY 74
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110
Practice Address - Country:US
Practice Address - Phone:704-282-1445
Practice Address - Fax:704-290-1035
Is Sole Proprietor?:No
Enumeration Date:2011-06-04
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12147183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist