Provider Demographics
NPI:1043841885
Name:JOHANSON, GINA TERESA (PHARMD)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:TERESA
Last Name:JOHANSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47726 SD HIGHWAY 32
Mailing Address - Street 2:
Mailing Address - City:FLANDREAU
Mailing Address - State:SD
Mailing Address - Zip Code:57028-6719
Mailing Address - Country:US
Mailing Address - Phone:605-941-5201
Mailing Address - Fax:
Practice Address - Street 1:403 W BROAD AVE
Practice Address - Street 2:
Practice Address - City:FLANDREAU
Practice Address - State:SD
Practice Address - Zip Code:57028-1630
Practice Address - Country:US
Practice Address - Phone:605-997-2642
Practice Address - Fax:605-997-2586
Is Sole Proprietor?:No
Enumeration Date:2020-01-30
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD6573183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist