Provider Demographics
NPI:1922393545
Name:JOHNSON, KENT
Entity Type:Individual
Prefix:
First Name:KENT
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 HIGHWAY 10 E
Mailing Address - Street 2:T0658
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-2516
Mailing Address - Country:US
Mailing Address - Phone:218-233-2953
Mailing Address - Fax:218-233-2953
Practice Address - Street 1:3301 HIGHWAY 10 E
Practice Address - Street 2:T0658
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-2516
Practice Address - Country:US
Practice Address - Phone:218-233-2953
Practice Address - Fax:218-233-2953
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-10
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN112738183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist