Provider Demographics
NPI:1164697058
Name:JOHNSON, MARK ROBERT (RPH)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ROBERT
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 1:2688 N SHERMAN RD
Mailing Address - Street 2:
Mailing Address - City:LUDINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:49431-9598
Mailing Address - Country:US
Mailing Address - Phone:231-843-1975
Mailing Address - Fax:231-845-8674
Practice Address - Street 1:936 E LUDINGTON AVE
Practice Address - Street 2:
Practice Address - City:LUDINGTON
Practice Address - State:MI
Practice Address - Zip Code:49431-2438
Practice Address - Country:US
Practice Address - Phone:231-845-7332
Practice Address - Fax:213-845-8674
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302023036183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302023036OtherPHARMACIST