Provider Demographics
NPI:1205474780
Name:JOHNSON, ANDERS CHRISTEN
Entity type:Individual
Prefix:
First Name:ANDERS
Middle Name:CHRISTEN
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 1:12780 CONESTOGA WAY
Mailing Address - Street 2:
Mailing Address - City:LOLO
Mailing Address - State:MT
Mailing Address - Zip Code:59847-8475
Mailing Address - Country:US
Mailing Address - Phone:406-544-6089
Mailing Address - Fax:
Practice Address - Street 1:301 MAIN ST
Practice Address - Street 2:
Practice Address - City:STEVENSVILLE
Practice Address - State:MT
Practice Address - Zip Code:59870-2597
Practice Address - Country:US
Practice Address - Phone:406-777-5591
Practice Address - Fax:406-777-5451
Is Sole Proprietor?:No
Enumeration Date:2019-12-16
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT3962183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT81-1193183Medicaid