Provider Demographics
NPI:1669716700
Name:JOHNSON, LISA A (RPH)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:A
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 1:121 E BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-2312
Mailing Address - Country:US
Mailing Address - Phone:989-773-5544
Mailing Address - Fax:
Practice Address - Street 1:121 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-2312
Practice Address - Country:US
Practice Address - Phone:989-773-5544
Practice Address - Fax:989-775-7622
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302027343183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist