Provider Demographics
NPI:1972820736
Name:ANDERSON, ELLEN (PHARMD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PHARMD
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 T
Mailing Address - Street 2:112 2ND STREET E
Mailing Address - City:WINTHROP
Mailing Address - State:MN
Mailing Address - Zip Code:55396
Mailing Address - Country:US
Mailing Address - Phone:507-647-8800
Mailing Address - Fax:507-647-8805
Practice Address - Street 1:112 EAST SECOND STREET.
Practice Address - Street 2:
Practice Address - City:WINTHROP
Practice Address - State:MN
Practice Address - Zip Code:55396
Practice Address - Country:US
Practice Address - Phone:507-647-8800
Practice Address - Fax:507-647-8805
Is Sole Proprietor?:No
Enumeration Date:2010-05-03
Last Update Date:2011-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN116992183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist