Provider Demographics
NPI:1396083655
Name:JOHNSON, MATTHEW (RPH)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
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:PO BOX 17
Mailing Address - Street 2:
Mailing Address - City:AMERY
Mailing Address - State:WI
Mailing Address - Zip Code:54001-0017
Mailing Address - Country:US
Mailing Address - Phone:715-268-8121
Mailing Address - Fax:715-268-4733
Practice Address - Street 1:204 KELLER AVE N
Practice Address - Street 2:
Practice Address - City:AMERY
Practice Address - State:WI
Practice Address - Zip Code:54001-1036
Practice Address - Country:US
Practice Address - Phone:715-268-8121
Practice Address - Fax:715-268-4733
Is Sole Proprietor?:No
Enumeration Date:2013-01-22
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11513-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist