Provider Demographics
NPI:1962563072
Name:JOHNSON, STAN D (DPH)
Entity type:Individual
Prefix:MR
First Name:STAN
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3802 QUAIL DR
Mailing Address - Street 2:
Mailing Address - City:WOODWARD
Mailing Address - State:OK
Mailing Address - Zip Code:73801-5264
Mailing Address - Country:US
Mailing Address - Phone:580-256-5479
Mailing Address - Fax:
Practice Address - Street 1:2821 8TH ST
Practice Address - Street 2:
Practice Address - City:WOODWARD
Practice Address - State:OK
Practice Address - Zip Code:73801-6721
Practice Address - Country:US
Practice Address - Phone:580-256-5479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK9524183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist