Provider Demographics
NPI:1245579929
Name:JOHNSON, MICHAEL A (RPH)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:A
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:N1125 1000TH ST
Mailing Address - Street 2:
Mailing Address - City:MONDOVI
Mailing Address - State:WI
Mailing Address - Zip Code:54755-9409
Mailing Address - Country:US
Mailing Address - Phone:715-875-4817
Mailing Address - Fax:
Practice Address - Street 1:1707 WESTGATE RD
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54703-4964
Practice Address - Country:US
Practice Address - Phone:715-838-5856
Practice Address - Fax:715-838-5861
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-31
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9460-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist