Provider Demographics
NPI:1275157851
Name:ANDERSON, JANELLE ALIVIA
Entity Type:Individual
Prefix:
First Name:JANELLE
Middle Name:ALIVIA
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7000 DOUGLAS AVE
Mailing Address - Street 2:
Mailing Address - City:URBANDALE
Mailing Address - State:IA
Mailing Address - Zip Code:50322-3224
Mailing Address - Country:US
Mailing Address - Phone:515-276-4903
Mailing Address - Fax:515-276-0296
Practice Address - Street 1:7000 DOUGLAS AVE
Practice Address - Street 2:
Practice Address - City:URBANDALE
Practice Address - State:IA
Practice Address - Zip Code:50322-3224
Practice Address - Country:US
Practice Address - Phone:515-276-4903
Practice Address - Fax:515-276-0296
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-30
Last Update Date:2020-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA23443183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist