Provider Demographics
NPI:1548400294
Name:JOHNSON, TIMOTHY (RPH)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6228 URBANDALE LN N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311
Mailing Address - Country:US
Mailing Address - Phone:763-331-0286
Mailing Address - Fax:
Practice Address - Street 1:2855 CAMPUS DR
Practice Address - Street 2:SUITE 180
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-2649
Practice Address - Country:US
Practice Address - Phone:763-577-7007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-20
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN115034183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist