Provider Demographics
NPI:1750512430
Name:ANDERSON, RICHARD L
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:L
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 1:467 SALEM ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-3336
Mailing Address - Country:US
Mailing Address - Phone:781-396-1027
Mailing Address - Fax:781-396-2556
Practice Address - Street 1:467 SALEM ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-3336
Practice Address - Country:US
Practice Address - Phone:781-396-1027
Practice Address - Fax:781-396-2556
Is Sole Proprietor?:No
Enumeration Date:2009-07-29
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA23031183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist