Provider Demographics
NPI:1447386883
Name:ANDERSON, MARY M (RPH)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:M
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 1:1201 MORTON RD
Mailing Address - Street 2:
Mailing Address - City:HORTON
Mailing Address - State:MI
Mailing Address - Zip Code:49246-9626
Mailing Address - Country:US
Mailing Address - Phone:517-688-3496
Mailing Address - Fax:517-688-3468
Practice Address - Street 1:2255 S JACKSON RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-8344
Practice Address - Country:US
Practice Address - Phone:517-780-9535
Practice Address - Fax:517-782-9401
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302023026183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist