Provider Demographics
NPI:1003037235
Name:JOHNSON, OWEN W (RPH)
Entity type:Individual
Prefix:MR
First Name:OWEN
Middle Name:W
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 1:8800 NORTH BROOK CIRCLE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55428
Mailing Address - Country:US
Mailing Address - Phone:763-536-8042
Mailing Address - Fax:
Practice Address - Street 1:4445 N. NATHAN LANE
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55442
Practice Address - Country:US
Practice Address - Phone:763-557-0377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN111477183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist