Provider Demographics
NPI:1114298411
Name:ANDRES, MARK LEWIS (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:LEWIS
Last Name:ANDRES
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 1:620 W PLATTE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT MORGAN
Mailing Address - State:CO
Mailing Address - Zip Code:80701-2652
Mailing Address - Country:US
Mailing Address - Phone:970-867-3027
Mailing Address - Fax:
Practice Address - Street 1:620 W PLATTE AVE
Practice Address - Street 2:
Practice Address - City:FORT MORGAN
Practice Address - State:CO
Practice Address - Zip Code:80701-2652
Practice Address - Country:US
Practice Address - Phone:970-867-3027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-18
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO19337183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist