Provider Demographics
NPI:1124437785
Name:JOHNSON HENDERSON, DORY
Entity type:Individual
Prefix:
First Name:DORY
Middle Name:
Last Name:JOHNSON HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DORY
Other - Middle Name:DEE
Other - Last Name:HENDERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:1700 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59601-1108
Mailing Address - Country:US
Mailing Address - Phone:406-475-3025
Mailing Address - Fax:406-443-1243
Practice Address - Street 1:1700 CEDAR ST
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601-1108
Practice Address - Country:US
Practice Address - Phone:406-475-3025
Practice Address - Fax:406-443-1243
Is Sole Proprietor?:No
Enumeration Date:2014-08-07
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT3309183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTPHA-PHA-LIC-3309OtherPHARMACIST LICENSE