1124437785 NPI number — DORY JOHNSON HENDERSON

Table of content: DORY JOHNSON HENDERSON (NPI 1124437785)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124437785 NPI number — DORY JOHNSON HENDERSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON HENDERSON
Provider First Name:
DORY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HENDERSON
Provider Other First Name:
DORY
Provider Other Middle Name:
DEE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RPH
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1124437785
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/07/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1700 CEDAR ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HELENA
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59601-1108
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-475-3025
Provider Business Mailing Address Fax Number:
406-443-1243

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1700 CEDAR ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HELENA
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59601-1108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-475-3025
Provider Business Practice Location Address Fax Number:
406-443-1243
Provider Enumeration Date:
08/07/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  3309 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PHA-PHA-LIC-3309 . This is a "PHARMACIST LICENSE" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".




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