Provider Demographics
NPI:1376896084
Name:ANDERSON, CHARLES NOLIS (PHARM D)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:NOLIS
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:457 E 41ST ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60653-2705
Mailing Address - Country:US
Mailing Address - Phone:773-808-4310
Mailing Address - Fax:
Practice Address - Street 1:17605 S. HALSTED STREET
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430
Practice Address - Country:US
Practice Address - Phone:708-335-5250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-18
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051296289183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist