Provider Demographics
NPI:1306835061
Name:ANDERSON, J CALVIN
Entity Type:Individual
Prefix:
First Name:J
Middle Name:CALVIN
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 MAGNOLIA LOOP
Mailing Address - Street 2:
Mailing Address - City:MILLBROOK
Mailing Address - State:AL
Mailing Address - Zip Code:36054-2536
Mailing Address - Country:US
Mailing Address - Phone:334-285-4395
Mailing Address - Fax:
Practice Address - Street 1:300 TWINING STREET
Practice Address - Street 2:
Practice Address - City:MAXWELL AFB
Practice Address - State:AL
Practice Address - Zip Code:36112
Practice Address - Country:US
Practice Address - Phone:334-285-4395
Practice Address - Fax:334-953-8296
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL15040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist