Provider Demographics
NPI:1962743070
Name:JOHNSON, PENELOPE AVRA (PHARMD, BCPS)
Entity type:Individual
Prefix:
First Name:PENELOPE
Middle Name:AVRA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHARMD, BCPS
Other - Prefix:
Other - First Name:PENELOPE
Other - Middle Name:AVRA
Other - Last Name:MANOLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3141 CENTENNIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-4094
Mailing Address - Country:US
Mailing Address - Phone:719-227-4366
Mailing Address - Fax:719-227-4655
Practice Address - Street 1:3141 CENTENNIAL BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-4094
Practice Address - Country:US
Practice Address - Phone:719-227-4366
Practice Address - Fax:719-227-4655
Is Sole Proprietor?:No
Enumeration Date:2013-03-14
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO149951835P0018X, 1835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist