Provider Demographics
NPI:1083216840
Name:ANDERSON, MINDY (RPH)
Entity Type:Individual
Prefix:MRS
First Name:MINDY
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 S TALLAHASSEE ST
Mailing Address - Street 2:
Mailing Address - City:HAZLEHURST
Mailing Address - State:GA
Mailing Address - Zip Code:31539-6157
Mailing Address - Country:US
Mailing Address - Phone:912-375-7729
Mailing Address - Fax:912-379-0814
Practice Address - Street 1:92 S TALLAHASSEE ST
Practice Address - Street 2:
Practice Address - City:HAZLEHURST
Practice Address - State:GA
Practice Address - Zip Code:31539-6157
Practice Address - Country:US
Practice Address - Phone:912-385-7729
Practice Address - Fax:912-379-0814
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA017668183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist