Provider Demographics
NPI:1902232895
Name:ANDERSON, HUSTON P (R PH)
Entity Type:Individual
Prefix:MR
First Name:HUSTON
Middle Name:P
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13750 ROAD 42
Mailing Address - Street 2:
Mailing Address - City:MANCOS
Mailing Address - State:CO
Mailing Address - Zip Code:81328
Mailing Address - Country:US
Mailing Address - Phone:970-533-9775
Mailing Address - Fax:
Practice Address - Street 1:13750 ROAD 42
Practice Address - Street 2:
Practice Address - City:MANCOS
Practice Address - State:CO
Practice Address - Zip Code:81328-9009
Practice Address - Country:US
Practice Address - Phone:970-533-9775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-24
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO13494183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist