Provider Demographics
NPI:1700222544
Name:JOHNSON, KENNETH PAUL (R PH)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:PAUL
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 AUGSBURG AVE
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58504-7005
Mailing Address - Country:US
Mailing Address - Phone:701-258-5380
Mailing Address - Fax:
Practice Address - Street 1:506 AUGSBURG AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-7005
Practice Address - Country:US
Practice Address - Phone:701-258-5380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-20
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDRPH3397183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist