Provider Demographics
NPI:1730531856
Name:JOHNSON, MCKENZIE I (PHARM D)
Entity type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:
Last Name:JOHNSON
Suffix:I
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 43RD AVE S
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-3460
Mailing Address - Country:US
Mailing Address - Phone:218-289-4037
Mailing Address - Fax:182-816-1722
Practice Address - Street 1:1930 SAHLSTROM DR
Practice Address - Street 2:
Practice Address - City:CROOKSTON
Practice Address - State:MN
Practice Address - Zip Code:56716-2819
Practice Address - Country:US
Practice Address - Phone:218-281-6170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-13
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDRPH5868183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist