Provider Demographics
NPI:1467471979
Name:JOHNSON, LESLIE A (PHARMACIST)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 PIEDMONT AVE
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-2915
Mailing Address - Country:US
Mailing Address - Phone:218-733-1110
Mailing Address - Fax:218-733-1112
Practice Address - Street 1:2900 PIEDMONT AVE
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811-2915
Practice Address - Country:US
Practice Address - Phone:218-733-1110
Practice Address - Fax:218-733-1112
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN110882-0183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist