Provider Demographics
NPI:1629930722
Name:ANDERSON, IAN KENNETH (PHARMD)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:KENNETH
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 1:3123 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-6972
Mailing Address - Country:US
Mailing Address - Phone:208-367-3131
Mailing Address - Fax:
Practice Address - Street 1:3123 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-6972
Practice Address - Country:US
Practice Address - Phone:208-367-3131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-11-26
Last Update Date:2025-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP92391835X0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835X0200XPharmacy Service ProvidersPharmacistOncology