Provider Demographics
NPI:1851730113
Name:ANDERSON, DEANNE MARIE (RPH)
Entity Type:Individual
Prefix:
First Name:DEANNE
Middle Name:MARIE
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:PO BOX 359
Mailing Address - Street 2:2040 SECOND ST
Mailing Address - City:LAKE PARK
Mailing Address - State:MN
Mailing Address - Zip Code:56554
Mailing Address - Country:US
Mailing Address - Phone:218-238-6642
Mailing Address - Fax:
Practice Address - Street 1:2040 SECOND ST
Practice Address - Street 2:
Practice Address - City:LAKE PARK
Practice Address - State:MN
Practice Address - Zip Code:56554
Practice Address - Country:US
Practice Address - Phone:218-238-6642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-20
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN114273183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist