Provider Demographics
NPI:1003170242
Name:ANDERSON, BRANDON LEE (PHARMD, MBA)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:LEE
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PHARMD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3051 WILLIAMS STREET
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-6393
Mailing Address - Country:US
Mailing Address - Phone:573-339-0909
Mailing Address - Fax:
Practice Address - Street 1:3051 WILLIAM ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-6393
Practice Address - Country:US
Practice Address - Phone:573-339-0909
Practice Address - Fax:573-339-5940
Is Sole Proprietor?:No
Enumeration Date:2012-07-03
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009030884183500000X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1619180130Medicaid