Provider Demographics
NPI:1407341332
Name:DOHERTY-JOHNSEN, SHELLEY LYNN (RPH)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:LYNN
Last Name:DOHERTY-JOHNSEN
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 1:20221 60TH AVE S
Mailing Address - Street 2:
Mailing Address - City:HAWLEY
Mailing Address - State:MN
Mailing Address - Zip Code:56549-9036
Mailing Address - Country:US
Mailing Address - Phone:701-361-2138
Mailing Address - Fax:218-486-5327
Practice Address - Street 1:1106 HOBART ST
Practice Address - Street 2:
Practice Address - City:HAWLEY
Practice Address - State:MN
Practice Address - Zip Code:56549-4000
Practice Address - Country:US
Practice Address - Phone:218-486-4663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-23
Last Update Date:2018-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN116485183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist