Provider Demographics
NPI:1306836432
Name:ANDERSON, MICHAEL LARRY (DPH)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LARRY
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2571
Mailing Address - Street 2:
Mailing Address - City:ALMA
Mailing Address - State:AR
Mailing Address - Zip Code:72921-2571
Mailing Address - Country:US
Mailing Address - Phone:479-632-5472
Mailing Address - Fax:
Practice Address - Street 1:RR 6
Practice Address - Street 2:
Practice Address - City:STILWELL
Practice Address - State:OK
Practice Address - Zip Code:74960-9806
Practice Address - Country:US
Practice Address - Phone:918-696-8821
Practice Address - Fax:918-696-8881
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK9202183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist