Provider Demographics
NPI:1215133004
Name:JOHNSON, MARK (PHARMACIST)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1480 LEE ST
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60018-1517
Mailing Address - Country:US
Mailing Address - Phone:847-299-8185
Mailing Address - Fax:847-299-3209
Practice Address - Street 1:1480 LEE ST
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60018-1517
Practice Address - Country:US
Practice Address - Phone:847-299-8185
Practice Address - Fax:847-299-3209
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist