Provider Demographics
NPI:1407199201
Name:JOHNSON, ROBERT G
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:G
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N1159 JOHNSON LN
Mailing Address - Street 2:
Mailing Address - City:MERRILL
Mailing Address - State:WI
Mailing Address - Zip Code:54452-8306
Mailing Address - Country:US
Mailing Address - Phone:715-536-6695
Mailing Address - Fax:
Practice Address - Street 1:1021 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MERRILL
Practice Address - State:WI
Practice Address - Zip Code:54452-2504
Practice Address - Country:US
Practice Address - Phone:715-539-2772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-29
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8553183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist