Provider Demographics
NPI:1407583610
Name:ANDERSON, LARS
Entity Type:Individual
Prefix:
First Name:LARS
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 CENTRAL AVE E
Mailing Address - Street 2:
Mailing Address - City:SAINT MICHAEL
Mailing Address - State:MN
Mailing Address - Zip Code:55376-4594
Mailing Address - Country:US
Mailing Address - Phone:763-497-7069
Mailing Address - Fax:763-497-3605
Practice Address - Street 1:900 CENTRAL AVE E
Practice Address - Street 2:
Practice Address - City:SAINT MICHAEL
Practice Address - State:MN
Practice Address - Zip Code:55376-4594
Practice Address - Country:US
Practice Address - Phone:763-497-7069
Practice Address - Fax:763-497-3605
Is Sole Proprietor?:No
Enumeration Date:2022-08-07
Last Update Date:2022-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN125680183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist