Provider Demographics
NPI:1326066788
Name:ANDERSON, JEFFREY ALLAN (DPH)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:ALLAN
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 368
Mailing Address - Street 2:ANDERSON DRUGS & HOME CARE CENTER
Mailing Address - City:ETOWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37331
Mailing Address - Country:US
Mailing Address - Phone:423-263-7824
Mailing Address - Fax:423-263-5714
Practice Address - Street 1:725 TENNESSEE AVE
Practice Address - Street 2:
Practice Address - City:ETOWAH
Practice Address - State:TN
Practice Address - Zip Code:37331
Practice Address - Country:US
Practice Address - Phone:423-263-7824
Practice Address - Fax:423-263-5714
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6691183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1454338Medicaid
TN1454338Medicaid