Provider Demographics
NPI:1356412282
Name:JOHNSON, DENISE MARIE (RPH)
Entity type:Individual
Prefix:
First Name:DENISE
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 1:13895 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-8820
Mailing Address - Country:US
Mailing Address - Phone:616-846-0716
Mailing Address - Fax:616-394-6508
Practice Address - Street 1:646 S WAVERLY RD
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-9121
Practice Address - Country:US
Practice Address - Phone:616-394-6501
Practice Address - Fax:616-394-6508
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302022615183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302022615OtherRPH LICENSE NUMBER