Healthcare Provider Details

I. General information

NPI: 1619882941
Provider Name (Legal Business Name): BETHANY GRACE JOHNSON PHARM.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2026
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3650 VICTORIA ST N
SHOREVIEW MN
55126-2906
US

IV. Provider business mailing address

3650 VICTORIA ST N
SHOREVIEW MN
55126-2906
US

V. Phone/Fax

Practice location:
  • Phone: 612-672-5737
  • Fax: 612-672-5738
Mailing address:
  • Phone: 612-672-5737
  • Fax: 612-672-5738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number121718
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: