Provider Demographics
NPI:1295205102
Name:ANDERSON, DAVID L (PHARMD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:L
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 1:350 S VAN BUREN ST STE F
Mailing Address - Street 2:
Mailing Address - City:SHIPSHEWANA
Mailing Address - State:IN
Mailing Address - Zip Code:46565-9197
Mailing Address - Country:US
Mailing Address - Phone:260-768-4433
Mailing Address - Fax:260-768-4403
Practice Address - Street 1:350 S VAN BUREN ST STE F
Practice Address - Street 2:
Practice Address - City:SHIPSHEWANA
Practice Address - State:IN
Practice Address - Zip Code:46565-9197
Practice Address - Country:US
Practice Address - Phone:260-768-4433
Practice Address - Fax:260-768-4403
Is Sole Proprietor?:No
Enumeration Date:2018-12-04
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26022099A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN26022099AOtherPHARMACIST LICENSE