Provider Demographics
NPI:1215444070
Name:JOHNSON, AMANDA (PHARMD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
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 1:3621 LANCASTER LN N APT 303
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-6601
Mailing Address - Country:US
Mailing Address - Phone:763-228-6484
Mailing Address - Fax:
Practice Address - Street 1:6150 EGAN DR
Practice Address - Street 2:
Practice Address - City:SAVAGE
Practice Address - State:MN
Practice Address - Zip Code:55378-2699
Practice Address - Country:US
Practice Address - Phone:952-228-2552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-02
Last Update Date:2018-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN123503183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist