Provider Demographics
NPI:1689027179
Name:ANDERSON, PHILIP
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:
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 1:524 TYHEE AVE
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83211-1224
Mailing Address - Country:US
Mailing Address - Phone:208-226-2411
Mailing Address - Fax:
Practice Address - Street 1:524 TYHEE AVE
Practice Address - Street 2:
Practice Address - City:AMERICAN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83211-1224
Practice Address - Country:US
Practice Address - Phone:208-226-2411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-19
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP7578183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0347100001Medicaid