Provider Demographics
NPI:1861875171
Name:JOHNSON, AMY
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69542 HAEFER LANE
Mailing Address - Street 2:
Mailing Address - City:COVE
Mailing Address - State:OR
Mailing Address - Zip Code:97824
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1123 ADAMS AVE
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850
Practice Address - Country:US
Practice Address - Phone:541-963-5741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-06
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0014388183500000X
WY3567183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist