Provider Demographics
NPI:1841556263
Name:ANDERSON, ADAM LESLIE (PHARMD, RPH)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:LESLIE
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 1:51670 HUNTINGTON RD
Mailing Address - Street 2:PO BOX 1976
Mailing Address - City:LA PINE
Mailing Address - State:OR
Mailing Address - Zip Code:97739-9626
Mailing Address - Country:US
Mailing Address - Phone:541-536-5052
Mailing Address - Fax:541-536-1488
Practice Address - Street 1:51670 HUNTINGTON RD
Practice Address - Street 2:
Practice Address - City:LA PINE
Practice Address - State:OR
Practice Address - Zip Code:97739-9626
Practice Address - Country:US
Practice Address - Phone:541-536-5052
Practice Address - Fax:541-536-1488
Is Sole Proprietor?:No
Enumeration Date:2012-04-10
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0012679183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORRPH-0012679OtherSTATE PHARMACIST LICENSE