Provider Demographics
NPI:1558790188
Name:JOHNSON, MARY E (CPHT, WPQC CERTIFIED)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CPHT, WPQC CERTIFIED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 WATER ST
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE DU SAC
Mailing Address - State:WI
Mailing Address - Zip Code:53578-1126
Mailing Address - Country:US
Mailing Address - Phone:608-643-3396
Mailing Address - Fax:608-643-4361
Practice Address - Street 1:405 WATER ST
Practice Address - Street 2:
Practice Address - City:PRAIRIE DU SAC
Practice Address - State:WI
Practice Address - Zip Code:53578-1126
Practice Address - Country:US
Practice Address - Phone:608-643-3396
Practice Address - Fax:608-643-4361
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-04
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI330101051154461183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician