Provider Demographics
NPI:1154608156
Name:JOHNSON, HEATHER LYNN (RPH)
Entity type:Individual
Prefix:MR
First Name:HEATHER
Middle Name:LYNN
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 1:5387 STAINES RD
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:MI
Mailing Address - Zip Code:48884-2140
Mailing Address - Country:US
Mailing Address - Phone:989-291-1171
Mailing Address - Fax:
Practice Address - Street 1:2450 S STATE RD
Practice Address - Street 2:
Practice Address - City:IONIA
Practice Address - State:MI
Practice Address - Zip Code:48846-2140
Practice Address - Country:US
Practice Address - Phone:616-522-9175
Practice Address - Fax:616-522-9286
Is Sole Proprietor?:No
Enumeration Date:2011-11-04
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302028827183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist