Provider Demographics
NPI:1447531553
Name:JOHNSON, ORSON
Entity type:Individual
Prefix:
First Name:ORSON
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 CROSSROADS PL
Mailing Address - Street 2:
Mailing Address - City:HIGH RIDGE
Mailing Address - State:MO
Mailing Address - Zip Code:63049-2234
Mailing Address - Country:US
Mailing Address - Phone:636-376-4785
Mailing Address - Fax:636-376-0714
Practice Address - Street 1:1000 CROSSROADS PL
Practice Address - Street 2:
Practice Address - City:HIGH RIDGE
Practice Address - State:MO
Practice Address - Zip Code:63049-2234
Practice Address - Country:US
Practice Address - Phone:636-376-4785
Practice Address - Fax:636-376-0714
Is Sole Proprietor?:No
Enumeration Date:2011-09-01
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO043618183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist