Provider Demographics
NPI:1093992703
Name:ANDERSON, WADE LEE (RPH)
Entity Type:Individual
Prefix:MR
First Name:WADE
Middle Name:LEE
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 N MAIN ST
Mailing Address - Street 2:PO BOX 51
Mailing Address - City:DEERFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53531-9453
Mailing Address - Country:US
Mailing Address - Phone:608-764-8111
Mailing Address - Fax:608-764-5556
Practice Address - Street 1:50 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DEERFIELD
Practice Address - State:WI
Practice Address - Zip Code:53531-9453
Practice Address - Country:US
Practice Address - Phone:608-764-8111
Practice Address - Fax:608-764-5556
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-24
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12604183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33274500Medicaid
1212000001Medicare NSC