Provider Demographics
NPI:1235740747
Name:JOHNSON, BETHANEY COLETTE (PHARMD)
Entity Type:Individual
Prefix:
First Name:BETHANEY
Middle Name:COLETTE
Last Name:JOHNSON
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 1:12349 5TH ST NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-2644
Mailing Address - Country:US
Mailing Address - Phone:720-252-7020
Mailing Address - Fax:
Practice Address - Street 1:5695 DULUTH ST
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422-4054
Practice Address - Country:US
Practice Address - Phone:763-546-5336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-10
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN123361183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist