Provider Demographics
NPI:1265947675
Name:JOHANSEN, GREGORY JAMES (RPH)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:JAMES
Last Name:JOHANSEN
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 1:2929 WESTOWN PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-1319
Mailing Address - Country:US
Mailing Address - Phone:515-440-1270
Mailing Address - Fax:
Practice Address - Street 1:2929 WESTOWN PKWY STE 100
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-1319
Practice Address - Country:US
Practice Address - Phone:515-440-1270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-07
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA14774183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA14774OtherIOWA PHARMACIST LICENCE