Provider Demographics
NPI:1962001727
Name:JOHNSON, AVERY CLARK (PHARMD)
Entity type:Individual
Prefix:
First Name:AVERY
Middle Name:CLARK
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 1:14372 S PEACOCK MIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BLUFFDALE
Mailing Address - State:UT
Mailing Address - Zip Code:84065-5620
Mailing Address - Country:US
Mailing Address - Phone:801-718-9255
Mailing Address - Fax:
Practice Address - Street 1:198 N 1200 E
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-2294
Practice Address - Country:US
Practice Address - Phone:801-653-2709
Practice Address - Fax:801-653-2706
Is Sole Proprietor?:No
Enumeration Date:2020-10-22
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT343987-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist