Provider Demographics
NPI:1760437347
Name:ANDERSON COMPOUNDING PHARMACY INC
Entity Type:Organization
Organization Name:ANDERSON COMPOUNDING PHARMACY INC
Other - Org Name:ANDERSON COMPOUNDING PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:ROY
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:423-764-4136
Mailing Address - Street 1:310 BLUFF CITY HWY
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-4602
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:310 BLUFF CITY HWY
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-4602
Practice Address - Country:US
Practice Address - Phone:423-764-4136
Practice Address - Fax:423-764-5167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TN21133336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0445728Medicaid
TN4425903Medicaid
VA8508895Medicaid
4425903OtherOTHER ID NUMBER
TN4425903Medicaid