Provider Demographics
NPI:1457846883
Name:JOHNSON, MICHELLE RENAE (RPH)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENAE
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 1:1994 ROGERS HILL RD
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76705-5726
Mailing Address - Country:US
Mailing Address - Phone:254-205-6029
Mailing Address - Fax:
Practice Address - Street 1:2401 E WACO DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76705-3259
Practice Address - Country:US
Practice Address - Phone:254-799-4949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-27
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35487183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist