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General NPI Number Information
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NPI Number | 1265169965
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Entity Type | Individual
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Provider Name | MEL JOHNSON
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Gender | Male
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Dates
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Enumeration Date | 08/02/2022
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Last Update Date | 08/02/2022
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Provider Practice Location Address
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Address Line | 700 30TH AVE S
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City | MOORHEAD
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State | MN
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Zip | 56560-4926
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Country | US
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Telephone | 218-331-2668
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Fax |
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Provider Business Mailing Address
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Address Line | 7671 CUB CREEK WAY
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City | HORACE
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State | ND
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Zip | 58047-5527
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Country | US
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Telephone | 218-234-4108
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 125619
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License Number State | MN
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