Provider Demographics
NPI:1508143751
Name:JOHNSON, SHELLY
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5023 SAGE BRUSH CT
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80023-3981
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5190 W 120TH AVE
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80020-3332
Practice Address - Country:US
Practice Address - Phone:303-410-1105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-15
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO16965183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist