Provider Demographics
NPI:1376834556
Name:JOHANSEN, KATHLEEN CHRISTINE (RPH)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:CHRISTINE
Last Name:JOHANSEN
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 1:1970 ECHO HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-7004
Mailing Address - Country:US
Mailing Address - Phone:541-461-0703
Mailing Address - Fax:
Practice Address - Street 1:1970 ECHO HOLLOW RD
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97402-7004
Practice Address - Country:US
Practice Address - Phone:541-461-0703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-22
Last Update Date:2011-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5224183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist