Provider Demographics
NPI:1720366198
Name:ANDERSON, JUANITA (RPH)
Entity Type:Individual
Prefix:
First Name:JUANITA
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 1:2096 HILLS CREEK RD
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30178-2039
Mailing Address - Country:US
Mailing Address - Phone:770-684-8414
Mailing Address - Fax:
Practice Address - Street 1:108 MERCHANTS SQUARE DR
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30121-2258
Practice Address - Country:US
Practice Address - Phone:770-334-3063
Practice Address - Fax:770-334-2114
Is Sole Proprietor?:No
Enumeration Date:2011-08-02
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH012145183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist