Provider Demographics
NPI:1396038592
Name:ANDERSON, DONNA JEAN
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:JEAN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
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 344
Mailing Address - Street 2:
Mailing Address - City:WEST LIBERTY
Mailing Address - State:KY
Mailing Address - Zip Code:41472-0344
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:275 PRESTONSBURG ST
Practice Address - Street 2:
Practice Address - City:WEST LIBERTY
Practice Address - State:KY
Practice Address - Zip Code:41472-1135
Practice Address - Country:US
Practice Address - Phone:606-743-3425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-20
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY007361183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist