Provider Demographics
NPI:1053909036
Name:JOHNSON, MIRANDA JEAN (DPH)
Entity type:Individual
Prefix:DR
First Name:MIRANDA
Middle Name:JEAN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 RIVERS RUN BLVD
Mailing Address - Street 2:
Mailing Address - City:OAK RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37830-9007
Mailing Address - Country:US
Mailing Address - Phone:865-719-0868
Mailing Address - Fax:
Practice Address - Street 1:FOOD CITY PHARMACY #654
Practice Address - Street 2:507 SOUTH CHARLES SEVIERS BLVD
Practice Address - City:CLINTON
Practice Address - State:TN
Practice Address - Zip Code:37716
Practice Address - Country:US
Practice Address - Phone:865-457-5259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-06
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN6362183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist