Provider Demographics
NPI:1003244229
Name:ANDERSON, JOHN A (RPH)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:A
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:523 11TH AVE N
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83687-3442
Mailing Address - Country:US
Mailing Address - Phone:208-466-2431
Mailing Address - Fax:208-466-2439
Practice Address - Street 1:523 11TH AVE N
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-3442
Practice Address - Country:US
Practice Address - Phone:208-466-2431
Practice Address - Fax:208-466-2439
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-25
Last Update Date:2013-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP3948183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist