Provider Demographics
NPI:1902115355
Name:JOHNSON, ERIC W (RPH)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:W
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 1:2517 GUNLOCK DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84118-2009
Mailing Address - Country:US
Mailing Address - Phone:801-967-0646
Mailing Address - Fax:
Practice Address - Street 1:70 YELLOW CREEK RD
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-5227
Practice Address - Country:US
Practice Address - Phone:307-789-0535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-04
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3369183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist