Provider Demographics
NPI:1801118542
Name:JOHNSON, BRIAN R (RPH)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:R
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 1:3201 WHITE BEAR AVE N
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-5402
Mailing Address - Country:US
Mailing Address - Phone:651-770-0311
Mailing Address - Fax:
Practice Address - Street 1:3201 WHITE BEAR AVE N
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-5402
Practice Address - Country:US
Practice Address - Phone:651-770-0311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-22
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN112050183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist