Provider Demographics
NPI:1972105476
Name:JOHNSON, MICHAEL LEW
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LEW
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:729 JACOBS LADDER PL
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89138-7540
Mailing Address - Country:US
Mailing Address - Phone:702-525-9837
Mailing Address - Fax:
Practice Address - Street 1:3615 S RAINBOW BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-1057
Practice Address - Country:US
Practice Address - Phone:702-367-6113
Practice Address - Fax:702-367-4179
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV16239183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist