Provider Demographics
NPI:1750849832
Name:ANDERSON, ROBERT JAY (PHARMD, RPH)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:JAY
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 BECK RD
Mailing Address - Street 2:
Mailing Address - City:NYSSA
Mailing Address - State:OR
Mailing Address - Zip Code:97913-5119
Mailing Address - Country:US
Mailing Address - Phone:208-680-5786
Mailing Address - Fax:
Practice Address - Street 1:4605 ENTERPRISE WAY STE 102
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-6889
Practice Address - Country:US
Practice Address - Phone:208-855-0701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-07
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP8202183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP8202OtherIDAHO PHARMACIST LICENSE