Provider Demographics
NPI:1003215203
Name:ANDERSON, ELLIOT RICHARD (PHARMD)
Entity Type:Individual
Prefix:
First Name:ELLIOT
Middle Name:RICHARD
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1951 OAK ST
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-3738
Mailing Address - Country:US
Mailing Address - Phone:269-665-8900
Mailing Address - Fax:
Practice Address - Street 1:1951 OAK ST
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-3738
Practice Address - Country:US
Practice Address - Phone:269-665-8900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-14
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26025937A183500000X
MI5302039877183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist