Provider Demographics
NPI:1558731281
Name:ANDERSON, COREY
Entity Type:Individual
Prefix:
First Name:COREY
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 1:3625 WILLIAMS BLVD.
Mailing Address - Street 2:
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70065
Mailing Address - Country:US
Mailing Address - Phone:504-466-6848
Mailing Address - Fax:504-466-6039
Practice Address - Street 1:3625 WILLIAMS BLVD.
Practice Address - Street 2:
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70065
Practice Address - Country:US
Practice Address - Phone:504-466-6848
Practice Address - Fax:504-466-6039
Is Sole Proprietor?:No
Enumeration Date:2015-10-07
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.020869183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist