Provider Demographics
NPI:1972581957
Name:JOHNSON, RANDY GORDON (RPH)
Entity type:Individual
Prefix:MR
First Name:RANDY
Middle Name:GORDON
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34617 SE 56TH PL
Mailing Address - Street 2:
Mailing Address - City:FALL CITY
Mailing Address - State:WA
Mailing Address - Zip Code:98024-8806
Mailing Address - Country:US
Mailing Address - Phone:425-246-9205
Mailing Address - Fax:
Practice Address - Street 1:34617 SE 56TH PL
Practice Address - Street 2:
Practice Address - City:FALL CITY
Practice Address - State:WA
Practice Address - Zip Code:98024-8806
Practice Address - Country:US
Practice Address - Phone:425-246-9205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-09
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00010990183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist