Provider Demographics
NPI:1679858658
Name:JOHNSON CROSBY, MARLO
Entity Type:Individual
Prefix:
First Name:MARLO
Middle Name:
Last Name:JOHNSON CROSBY
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 1:2808 WEST AVE UNIT A
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414
Mailing Address - Country:US
Mailing Address - Phone:218-730-7259
Mailing Address - Fax:
Practice Address - Street 1:1585 SHERIDAN AVE
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-3819
Practice Address - Country:US
Practice Address - Phone:307-587-2017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-20
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS016384183500000X
WI15418-40183500000X
MN116025183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist