Provider Demographics
NPI:1457363400
Name:JOHNSON, MARY WYNNE (RPH)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:WYNNE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7601 EVERGREEN WAY
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98203-6424
Mailing Address - Country:US
Mailing Address - Phone:425-355-9303
Mailing Address - Fax:
Practice Address - Street 1:7601 EVERGREEN WAY
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203-6424
Practice Address - Country:US
Practice Address - Phone:425-355-9303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO13141183500000X
NM4620183500000X
WA60266311183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist