Provider Demographics
NPI:1114293867
Name:ANDERSEN, PAUL CONRAD (183500000X)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:CONRAD
Last Name:ANDERSEN
Suffix:
Gender:M
Credentials:183500000X
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 MAIN AVE E
Mailing Address - Street 2:
Mailing Address - City:DEER RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:56636-8735
Mailing Address - Country:US
Mailing Address - Phone:218-246-8642
Mailing Address - Fax:
Practice Address - Street 1:117 MAIN AVE E
Practice Address - Street 2:
Practice Address - City:DEER RIVER
Practice Address - State:MN
Practice Address - Zip Code:56636-8735
Practice Address - Country:US
Practice Address - Phone:218-246-8642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-27
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN109635183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist