Provider Demographics
NPI:1710538178
Name:ANDERSON, JAMES MELVIN
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:MELVIN
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 1:1280 LEWIS RD
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-3572
Mailing Address - Country:US
Mailing Address - Phone:630-302-7305
Mailing Address - Fax:
Practice Address - Street 1:1640 S GALENA AVE
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-9611
Practice Address - Country:US
Practice Address - Phone:815-288-7797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-26
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051035797183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist