Provider Demographics
NPI:1790143998
Name:JOHNSON, TERRY SCOTT (RPH)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:SCOTT
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 1:216 WASHBURNE AVE
Mailing Address - Street 2:
Mailing Address - City:PAYNESVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:56362-1643
Mailing Address - Country:US
Mailing Address - Phone:320-243-3781
Mailing Address - Fax:320-243-2005
Practice Address - Street 1:216 WASHBURNE AVE
Practice Address - Street 2:
Practice Address - City:PAYNESVILLE
Practice Address - State:MN
Practice Address - Zip Code:56362-1643
Practice Address - Country:US
Practice Address - Phone:320-243-3781
Practice Address - Fax:320-243-2005
Is Sole Proprietor?:No
Enumeration Date:2016-02-02
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN114757183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist