Provider Demographics
NPI:1407143688
Name:ANDERSON, MARY ANN L (RPH)
Entity Type:Individual
Prefix:MRS
First Name:MARY ANN
Middle Name:L
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:197 GRAVOIS BLUFFS PLAZA DR
Mailing Address - Street 2:T1314
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-4013
Mailing Address - Country:US
Mailing Address - Phone:636-326-7508
Mailing Address - Fax:
Practice Address - Street 1:197 GRAVOIS BLUFFS PLAZA DR
Practice Address - Street 2:T1314
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-4013
Practice Address - Country:US
Practice Address - Phone:636-326-7508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-07
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO041279183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist