Provider Demographics
NPI:1235699703
Name:ANDERSON, POLLY NICOLE (PHARM D)
Entity Type:Individual
Prefix:
First Name:POLLY
Middle Name:NICOLE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:467 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WV
Mailing Address - Zip Code:25130-2200
Mailing Address - Country:US
Mailing Address - Phone:304-369-5170
Mailing Address - Fax:
Practice Address - Street 1:471 MAIN ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WV
Practice Address - Zip Code:25130-1223
Practice Address - Country:US
Practice Address - Phone:304-369-5170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-21
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0007932183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVRP0007932OtherWV PHAMACIST LICENSE