Provider Demographics
NPI:1689747628
Name:JOHNSON, RONALD BERNARD (RPH)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:BERNARD
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 1:1280 NURSERY HILL CT
Mailing Address - Street 2:
Mailing Address - City:ARDEN HILLS
Mailing Address - State:MN
Mailing Address - Zip Code:55112-5766
Mailing Address - Country:US
Mailing Address - Phone:651-639-0610
Mailing Address - Fax:651-647-9730
Practice Address - Street 1:720 SNELLING AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-1844
Practice Address - Country:US
Practice Address - Phone:651-645-8636
Practice Address - Fax:651-647-9730
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN111213-3183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FM111213-3OtherPHARMACY LIC