Provider Demographics
NPI:1952383465
Name:JOHNSON, ANN MARIE (RPH)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:MARIE
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 1:16 SNOWBIRD CT
Mailing Address - Street 2:
Mailing Address - City:NORTH MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56003-1637
Mailing Address - Country:US
Mailing Address - Phone:507-625-8658
Mailing Address - Fax:
Practice Address - Street 1:600 MAYWOOD AVE
Practice Address - Street 2:21 CARKOSKI COMMONS
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-7008
Practice Address - Country:US
Practice Address - Phone:507-389-2483
Practice Address - Fax:507-389-2206
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1138492183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1138492OtherLICENSE