Provider Demographics
NPI:1285839589
Name:JOHNSON, SUSAN JANE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:JANE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:189 N MEADOWBROOK RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711-9223
Mailing Address - Country:US
Mailing Address - Phone:217-793-0485
Mailing Address - Fax:
Practice Address - Street 1:1501 S DIRKSEN PKWY
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-2128
Practice Address - Country:US
Practice Address - Phone:217-527-8408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist