Provider Demographics
NPI:1679856124
Name:ANDERSON, LAURIE (RPH)
Entity Type:Individual
Prefix:MS
First Name:LAURIE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3273 WILLOW MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-7915
Mailing Address - Country:US
Mailing Address - Phone:817-789-9958
Mailing Address - Fax:770-942-9945
Practice Address - Street 1:794 S PARK ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3826
Practice Address - Country:US
Practice Address - Phone:770-838-1678
Practice Address - Fax:770-838-9352
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-21
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH024076183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist