Provider Demographics
NPI:1164437703
Name:ANDERSON'S PHARMACY, LLC
Entity Type:Organization
Organization Name:ANDERSON'S PHARMACY, LLC
Other - Org Name:ANDERSON'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PIC
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:STUART
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-237-6615
Mailing Address - Street 1:112 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:N CARROLLTON
Mailing Address - State:MS
Mailing Address - Zip Code:38947-2000
Mailing Address - Country:US
Mailing Address - Phone:662-237-9294
Mailing Address - Fax:662-237-9292
Practice Address - Street 1:112 E MAIN ST
Practice Address - Street 2:
Practice Address - City:N CARROLLTON
Practice Address - State:MS
Practice Address - Zip Code:38947-2000
Practice Address - Country:US
Practice Address - Phone:662-237-9294
Practice Address - Fax:662-237-9292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MS01580/1.13336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00033243Medicaid
2043327OtherPK