Provider Demographics
NPI:1205381209
Name:ANDERSON, DUSTIN BLAKE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:DUSTIN
Middle Name:BLAKE
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 1:815 THAYER AVE APT 524
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-4589
Mailing Address - Country:US
Mailing Address - Phone:585-813-1029
Mailing Address - Fax:
Practice Address - Street 1:10692 CAMPUS WAY S
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20774-1307
Practice Address - Country:US
Practice Address - Phone:585-813-1029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-18
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPH100002455183500000X
MD24310183500000X
NY061897183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist