Provider Demographics
NPI:1780016436
Name:ANDRESEN, LEROY ARNOLD (RPH)
Entity Type:Individual
Prefix:
First Name:LEROY
Middle Name:ARNOLD
Last Name:ANDRESEN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 1ST ST SW
Mailing Address - Street 2:SKYLARK MALL
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-4234
Mailing Address - Country:US
Mailing Address - Phone:320-235-8400
Mailing Address - Fax:320-235-7801
Practice Address - Street 1:1600 1ST ST SW
Practice Address - Street 2:SKYLARK MALL
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-4234
Practice Address - Country:US
Practice Address - Phone:320-235-8400
Practice Address - Fax:320-235-7801
Is Sole Proprietor?:No
Enumeration Date:2013-08-05
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN112935183500000X
ND3798183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist