Provider Demographics
NPI:1104217264
Name:ANDERSON, DANIEL (PHARMD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
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 1:3842 BANTAM DR
Mailing Address - Street 2:
Mailing Address - City:HUDSONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49426-7528
Mailing Address - Country:US
Mailing Address - Phone:616-915-3061
Mailing Address - Fax:
Practice Address - Street 1:3842 BANTAM DR
Practice Address - Street 2:
Practice Address - City:HUDSONVILLE
Practice Address - State:MI
Practice Address - Zip Code:49426-7528
Practice Address - Country:US
Practice Address - Phone:616-915-3061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-11
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302038749183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302038749OtherSTATE OF MICHIGAN - BOARD OF PHARMACY REGISTERED PHARMACIST LICENSE