Provider Demographics
NPI:1821235235
Name:ANDERSON, MYRNA KAY (RPH)
Entity Type:Individual
Prefix:
First Name:MYRNA
Middle Name:KAY
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 1:1823 15 1/2 ST SW
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-6184
Mailing Address - Country:US
Mailing Address - Phone:701-839-2286
Mailing Address - Fax:
Practice Address - Street 1:400 BURDICK EXPY E
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-4768
Practice Address - Country:US
Practice Address - Phone:701-857-7900
Practice Address - Fax:701-857-7834
Is Sole Proprietor?:No
Enumeration Date:2009-01-07
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND3056183500000X, 1835N1003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835N1003XPharmacy Service ProvidersPharmacistNutrition Support
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1093764599OtherNPI
ND20121Medicaid