1710984588 NPI number — MR. BRADLEY THIREN JOHNSON RPH,CGP,CDM

Table of content: MR. BRADLEY THIREN JOHNSON RPH,CGP,CDM (NPI 1710984588)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710984588 NPI number — MR. BRADLEY THIREN JOHNSON RPH,CGP,CDM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
BRADLEY
Provider Middle Name:
THIREN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
RPH,CGP,CDM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710984588
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1125 LORELLA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EUGENE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97401-7823
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-343-7162
Provider Business Mailing Address Fax Number:
541-242-8303

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4010 AERIAL WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EUGENE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97402-9757
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-242-8525
Provider Business Practice Location Address Fax Number:
541-242-8520
Provider Enumeration Date:
07/07/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  6258 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 1835P1200X , with the licence number: HD032131 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0759 . This is a "GERIATRIC CERTIFICATION" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 6258 . This is a "PHARMACY LISCENSE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: HD032131 . This is a "DIABETES MANAGMENT CERTIF" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".