Provider Demographics
NPI:1306351879
Name:JOHNSON, COLBY
Entity type:Individual
Prefix:
First Name:COLBY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 STAGECOACH LN
Mailing Address - Street 2:
Mailing Address - City:FORT MORGAN
Mailing Address - State:CO
Mailing Address - Zip Code:80701-4209
Mailing Address - Country:US
Mailing Address - Phone:605-390-9599
Mailing Address - Fax:
Practice Address - Street 1:1000 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:FORT MORGAN
Practice Address - State:CO
Practice Address - Zip Code:80701-3290
Practice Address - Country:US
Practice Address - Phone:605-390-9599
Practice Address - Fax:605-390-9599
Is Sole Proprietor?:No
Enumeration Date:2017-12-06
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0020963183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist