=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609474121
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SEMRA LISA JOHNSON RPH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2020
-----------------------------------------------------
Last Update Date | 10/16/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8760 NORTHRIDGE WAY
-----------------------------------------------------
City | MINOCQUA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54548-8766
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-356-3782
-----------------------------------------------------
Fax | 715-356-4883
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1960 N FARMING RD
-----------------------------------------------------
City | ARBOR VITAE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54568-9582
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-614-6206
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 11512
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------