Provider Demographics
NPI:1750708053
Name:JOHNSON, TIM (RPH)
Entity type:Individual
Prefix:MR
First Name:TIM
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
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:PO BOX 348
Mailing Address - Street 2:190 SOUTHGATE DR
Mailing Address - City:AITKIN
Mailing Address - State:MN
Mailing Address - Zip Code:56431-0348
Mailing Address - Country:US
Mailing Address - Phone:218-927-2466
Mailing Address - Fax:218-927-2597
Practice Address - Street 1:190 SOUTHGATE DR
Practice Address - Street 2:
Practice Address - City:AITKIN
Practice Address - State:MN
Practice Address - Zip Code:56431-7407
Practice Address - Country:US
Practice Address - Phone:218-927-2466
Practice Address - Fax:218-927-2597
Is Sole Proprietor?:No
Enumeration Date:2014-03-25
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN113724183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist