Provider Demographics
NPI:1831475516
Name:JOHNSON, KELLI J (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:J
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6061 OSGOOD AVE N
Mailing Address - Street 2:
Mailing Address - City:OAK PARK HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55082-6133
Mailing Address - Country:US
Mailing Address - Phone:651-689-0046
Mailing Address - Fax:651-689-0049
Practice Address - Street 1:6061 OSGOOD AVE N
Practice Address - Street 2:
Practice Address - City:OAK PARK HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55082-6133
Practice Address - Country:US
Practice Address - Phone:651-689-0046
Practice Address - Fax:651-689-0049
Is Sole Proprietor?:No
Enumeration Date:2011-10-26
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN116122183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist