Provider Demographics
NPI:1417265646
Name:ANDERSON, DONALD RAY (R PH)
Entity Type:Individual
Prefix:MR
First Name:DONALD
Middle Name:RAY
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8468 E AMETHYST PL
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85750-9788
Mailing Address - Country:US
Mailing Address - Phone:520-749-4624
Mailing Address - Fax:
Practice Address - Street 1:8730 E BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-4016
Practice Address - Country:US
Practice Address - Phone:520-290-0667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-22
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS010170183500000X
IN26013258A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist