Provider Demographics
NPI:1376840108
Name:JOHNSON, MARC E (RPH, MBA)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:RPH, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11921 N CANTATA DR
Mailing Address - Street 2:
Mailing Address - City:ORO VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85737-3767
Mailing Address - Country:US
Mailing Address - Phone:440-724-3180
Mailing Address - Fax:
Practice Address - Street 1:11921 N CANTATA DR
Practice Address - Street 2:
Practice Address - City:ORO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85737-3767
Practice Address - Country:US
Practice Address - Phone:440-724-3180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-14
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302025399183500000X
AZ018395183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist