Provider Demographics
NPI:1861191603
Name:JOHNSON, MATHEW (PHARMD)
Entity type:Individual
Prefix:
First Name:MATHEW
Middle Name:
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 1:326 ROXALANA HILLS DR
Mailing Address - Street 2:
Mailing Address - City:DUNBAR
Mailing Address - State:WV
Mailing Address - Zip Code:25064-1922
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:501 MORRIS ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1326
Practice Address - Country:US
Practice Address - Phone:304-388-3417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-01
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP00107591835C0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835C0205XPharmacy Service ProvidersPharmacistCritical Care