Provider Demographics
NPI:1528302635
Name:JOHNSON, KENNETH JAMES (RPH)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:JAMES
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8145 RHODE ISLAND CIR
Mailing Address - Street 2:1
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55438-1152
Mailing Address - Country:US
Mailing Address - Phone:952-943-1023
Mailing Address - Fax:
Practice Address - Street 1:8145 RHODE ISLAND CIR
Practice Address - Street 2:1
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55438-1152
Practice Address - Country:US
Practice Address - Phone:952-943-1023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN111783183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist