Provider Demographics
NPI:1164508313
Name:ANDERSEN, GAYLE LYNN (RPH)
Entity Type:Individual
Prefix:
First Name:GAYLE
Middle Name:LYNN
Last Name:ANDERSEN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1162 SW 102ND CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33174-2731
Mailing Address - Country:US
Mailing Address - Phone:305-559-7412
Mailing Address - Fax:
Practice Address - Street 1:18300 SW 137TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33177-6482
Practice Address - Country:US
Practice Address - Phone:305-234-9411
Practice Address - Fax:305-234-9942
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL15031183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist