Provider Demographics
NPI:1427342765
Name:JOHNSON, KARISSA LEE (RPH)
Entity type:Individual
Prefix:MRS
First Name:KARISSA
Middle Name:LEE
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 1:4370 VENTURE DR
Mailing Address - Street 2:T0929
Mailing Address - City:PERU
Mailing Address - State:IL
Mailing Address - Zip Code:61354-1013
Mailing Address - Country:US
Mailing Address - Phone:815-224-2408
Mailing Address - Fax:815-224-2408
Practice Address - Street 1:4370 VENTURE DR
Practice Address - Street 2:T0929
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-1013
Practice Address - Country:US
Practice Address - Phone:815-224-2408
Practice Address - Fax:815-224-2408
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-03
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-287297183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist