Provider Demographics
NPI:1316179567
Name:JOHNSON, HEATHER FAYE (RPH)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:FAYE
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 1:500 BURLINGTON ST SE
Mailing Address - Street 2:
Mailing Address - City:MANDAN
Mailing Address - State:ND
Mailing Address - Zip Code:58554-4281
Mailing Address - Country:US
Mailing Address - Phone:701-667-1843
Mailing Address - Fax:701-667-4352
Practice Address - Street 1:500 BURLINGTON ST SE
Practice Address - Street 2:
Practice Address - City:MANDAN
Practice Address - State:ND
Practice Address - Zip Code:58554-4281
Practice Address - Country:US
Practice Address - Phone:701-667-1843
Practice Address - Fax:701-667-4352
Is Sole Proprietor?:No
Enumeration Date:2009-08-20
Last Update Date:2010-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5251183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist