Provider Demographics
NPI:1851301519
Name:ANDERSON, PAUL R (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:R
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:PAUL
Other - Middle Name:R
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARMACIST
Mailing Address - Street 1:1719 TWELVE OAKS DR
Mailing Address - Street 2:
Mailing Address - City:TEXAS CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77591-2232
Mailing Address - Country:US
Mailing Address - Phone:409-935-5507
Mailing Address - Fax:
Practice Address - Street 1:1719 TWELVE OAKS DR
Practice Address - Street 2:
Practice Address - City:TEXAS CITY
Practice Address - State:TX
Practice Address - Zip Code:77591-2232
Practice Address - Country:US
Practice Address - Phone:409-935-5507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18095183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist