Provider Demographics
NPI:1801550173
Name:JOHNSON, SHIRLEY JEANNE (RPH)
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:JEANNE
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:PO BOX 495
Mailing Address - Street 2:
Mailing Address - City:TENINO
Mailing Address - State:WA
Mailing Address - Zip Code:98589-0495
Mailing Address - Country:US
Mailing Address - Phone:360-789-3919
Mailing Address - Fax:360-264-5039
Practice Address - Street 1:196 SUSSEX AVE W
Practice Address - Street 2:
Practice Address - City:TENINO
Practice Address - State:WA
Practice Address - Zip Code:98589-9327
Practice Address - Country:US
Practice Address - Phone:360-264-2575
Practice Address - Fax:360-264-5039
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-23
Last Update Date:2021-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00009923183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist