Provider Demographics
NPI:1508052655
Name:ANDERSON, ETHAN AARON (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:AARON
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16592 PILGRIM CT
Mailing Address - Street 2:
Mailing Address - City:LATHROP
Mailing Address - State:CA
Mailing Address - Zip Code:95330-8976
Mailing Address - Country:US
Mailing Address - Phone:209-545-4275
Mailing Address - Fax:
Practice Address - Street 1:3801 MIRANDA AVE
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-1207
Practice Address - Country:US
Practice Address - Phone:650-493-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-22
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60121183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist