Provider Demographics
NPI:1558646141
Name:ANDERSON, TRENT LEIGH (RPH)
Entity Type:Individual
Prefix:MR
First Name:TRENT
Middle Name:LEIGH
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 ROSE DR
Mailing Address - Street 2:PHARMACY
Mailing Address - City:BIG LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55309-8855
Mailing Address - Country:US
Mailing Address - Phone:763-263-7030
Mailing Address - Fax:763-263-8923
Practice Address - Street 1:711 ROSE DR
Practice Address - Street 2:PHARMACY
Practice Address - City:BIG LAKE
Practice Address - State:MN
Practice Address - Zip Code:55309-8855
Practice Address - Country:US
Practice Address - Phone:763-263-7030
Practice Address - Fax:763-263-8923
Is Sole Proprietor?:No
Enumeration Date:2011-10-14
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN113006183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist