Provider Demographics
NPI:1982741013
Name:JOHNSON, THEA LYNN (PHARMD)
Entity Type:Individual
Prefix:
First Name:THEA
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 CEDAR FALLS RD
Mailing Address - Street 2:
Mailing Address - City:MENOMONIE
Mailing Address - State:WI
Mailing Address - Zip Code:54751-1268
Mailing Address - Country:US
Mailing Address - Phone:715-235-7885
Mailing Address - Fax:715-235-6295
Practice Address - Street 1:180 CEDAR FALLS RD
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-1268
Practice Address - Country:US
Practice Address - Phone:715-235-7885
Practice Address - Fax:715-235-6295
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13672-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist