Provider Demographics
NPI:1669473765
Name:JOHNSON, BETTY LOU (RPH)
Entity Type:Individual
Prefix:
First Name:BETTY
Middle Name:LOU
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 1:18050 270TH ST
Mailing Address - Street 2:
Mailing Address - City:ELBOW LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56531-9103
Mailing Address - Country:US
Mailing Address - Phone:218-685-5193
Mailing Address - Fax:218-685-5209
Practice Address - Street 1:11 CENTRAL AVE S
Practice Address - Street 2:
Practice Address - City:ELBOW LAKE
Practice Address - State:MN
Practice Address - Zip Code:56531-4101
Practice Address - Country:US
Practice Address - Phone:218-685-4471
Practice Address - Fax:218-685-5209
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN113477-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN113477-1OtherPHARMACIST LICENSE