Provider Demographics
NPI:1710269253
Name:ANDERSON, LYNN MARIE
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:MARIE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4280 MINTON RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-9564
Mailing Address - Country:US
Mailing Address - Phone:321-951-9654
Mailing Address - Fax:
Practice Address - Street 1:4280 MINTON RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-9564
Practice Address - Country:US
Practice Address - Phone:321-951-9654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-11
Last Update Date:2011-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS22769183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist