Provider Demographics
NPI:1033786389
Name:ANDERSON, STEPHEN LAVERN
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:LAVERN
Last Name:ANDERSON
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:PO BOX 407
Mailing Address - Street 2:
Mailing Address - City:PURVIS
Mailing Address - State:MS
Mailing Address - Zip Code:39475-0407
Mailing Address - Country:US
Mailing Address - Phone:601-794-5525
Mailing Address - Fax:601-794-2741
Practice Address - Street 1:5796 US HIGHWAY 11
Practice Address - Street 2:
Practice Address - City:PURVIS
Practice Address - State:MS
Practice Address - Zip Code:39475-5004
Practice Address - Country:US
Practice Address - Phone:601-794-5525
Practice Address - Fax:601-794-2741
Is Sole Proprietor?:No
Enumeration Date:2021-06-07
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST08078183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist