Provider Demographics
NPI:1649792185
Name:JOHNSON, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 N LAKESHORE BLVD
Mailing Address - Street 2:
Mailing Address - City:HOWEY IN THE HILLS
Mailing Address - State:FL
Mailing Address - Zip Code:34737-3410
Mailing Address - Country:US
Mailing Address - Phone:352-602-6250
Mailing Address - Fax:
Practice Address - Street 1:1950 N STATE ROAD 19
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-6729
Practice Address - Country:US
Practice Address - Phone:352-357-5885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-15
Last Update Date:2017-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS56495183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist