Provider Demographics
NPI:1619273265
Name:JOHNSON, MARK THOMAS (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:THOMAS
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:935 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHELSEA
Mailing Address - State:MI
Mailing Address - Zip Code:48118-1330
Mailing Address - Country:US
Mailing Address - Phone:734-475-2222
Mailing Address - Fax:734-475-9268
Practice Address - Street 1:935 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CHELSEA
Practice Address - State:MI
Practice Address - Zip Code:48118-1330
Practice Address - Country:US
Practice Address - Phone:734-475-2222
Practice Address - Fax:734-475-9268
Is Sole Proprietor?:No
Enumeration Date:2011-01-31
Last Update Date:2020-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302033721183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist