Provider Demographics
NPI:1194053017
Name:JOHNSON, KIETRICH T (PHARMD)
Entity type:Individual
Prefix:DR
First Name:KIETRICH
Middle Name:T
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 1:11107 MARKET STREET RD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77029-2301
Mailing Address - Country:US
Mailing Address - Phone:713-451-9005
Mailing Address - Fax:
Practice Address - Street 1:11107 MARKET STREET RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77029-2301
Practice Address - Country:US
Practice Address - Phone:713-451-9005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-04
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX42290183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX462327Medicaid