Provider Demographics
NPI:1639469679
Name:ANDERSON, RICHARD R
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:R
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 1:1730 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILLITS
Mailing Address - State:CA
Mailing Address - Zip Code:95490-4405
Mailing Address - Country:US
Mailing Address - Phone:707-459-0554
Mailing Address - Fax:707-459-3230
Practice Address - Street 1:1730 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLITS
Practice Address - State:CA
Practice Address - Zip Code:95490-4405
Practice Address - Country:US
Practice Address - Phone:707-459-0554
Practice Address - Fax:707-459-3230
Is Sole Proprietor?:No
Enumeration Date:2011-04-11
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56931183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist