Provider Demographics
NPI:1952645582
Name:CARLSON, JOHN WILLIAM JR (RPH)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:WILLIAM
Last Name:CARLSON
Suffix:JR
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 1:30 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:MI
Mailing Address - Zip Code:49412-1244
Mailing Address - Country:US
Mailing Address - Phone:231-924-5965
Mailing Address - Fax:
Practice Address - Street 1:30 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:MI
Practice Address - Zip Code:49412-1244
Practice Address - Country:US
Practice Address - Phone:231-924-5965
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-20
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302025238183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist