Provider Demographics
NPI:1851417885
Name:ANDERSEN, WESLEY ALLEN (RPH)
Entity Type:Individual
Prefix:MR
First Name:WESLEY
Middle Name:ALLEN
Last Name:ANDERSEN
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 1:851 N KINGS RD APT 109
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90069-5931
Mailing Address - Country:US
Mailing Address - Phone:323-944-0710
Mailing Address - Fax:
Practice Address - Street 1:1223 16TH ST RM 1202
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1217
Practice Address - Country:US
Practice Address - Phone:760-325-9370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2013-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53637183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist