Provider Demographics
NPI:1609158948
Name:ANDERSON, CRAIG ROBERT (RPH)
Entity Type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:ROBERT
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 1:507 SHOSHONI TRL
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLA
Mailing Address - State:IL
Mailing Address - Zip Code:60046-5018
Mailing Address - Country:US
Mailing Address - Phone:847-356-3855
Mailing Address - Fax:
Practice Address - Street 1:709 N GREENBAY RD
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085
Practice Address - Country:US
Practice Address - Phone:847-662-8091
Practice Address - Fax:847-662-8186
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-13
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051030880183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist