Provider Demographics
NPI:1659972248
Name:ANDERSEN, WILLIAM LANCE (RPH)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:LANCE
Last Name:ANDERSEN
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 1:10809 S 2420 W
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-2633
Mailing Address - Country:US
Mailing Address - Phone:801-999-2795
Mailing Address - Fax:
Practice Address - Street 1:1202 W 12600 W
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065
Practice Address - Country:US
Practice Address - Phone:801-999-2795
Practice Address - Fax:801-999-2796
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-02
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT132813-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist