Provider Demographics
NPI:1215108493
Name:JOHNSON, GARY P (RPH)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:P
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:NY
Mailing Address - Zip Code:13865-0100
Mailing Address - Country:US
Mailing Address - Phone:607-655-1443
Mailing Address - Fax:607-655-3717
Practice Address - Street 1:112 MAIN ST
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:NY
Practice Address - Zip Code:13865-4129
Practice Address - Country:US
Practice Address - Phone:607-655-1443
Practice Address - Fax:607-655-3717
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-17
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027894183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01516994Medicaid
NY3348326OtherNABP
NY4016920001Medicare NSC