Provider Demographics
NPI:1316277767
Name:JOHNSON, SUSIE YOUNG
Entity type:Individual
Prefix:
First Name:SUSIE
Middle Name:YOUNG
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 1:3384 SQUIRE CREEK WAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40515-5392
Mailing Address - Country:US
Mailing Address - Phone:859-221-3535
Mailing Address - Fax:
Practice Address - Street 1:100 MALABU DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-3159
Practice Address - Country:US
Practice Address - Phone:859-278-2087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-07
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY014534183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist