Provider Demographics
NPI:1184786782
Name:ANDERSON PHARMACY
Entity type:Organization
Organization Name:ANDERSON PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER RPH
Authorized Official - Prefix:MR
Authorized Official - First Name:HAROLD
Authorized Official - Middle Name:G
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:218-843-2205
Mailing Address - Street 1:BX 99
Mailing Address - Street 2:115 S 2ND
Mailing Address - City:HALLOCK
Mailing Address - State:MN
Mailing Address - Zip Code:56728
Mailing Address - Country:US
Mailing Address - Phone:218-843-2205
Mailing Address - Fax:218-843-2205
Practice Address - Street 1:115 S 2ND
Practice Address - Street 2:
Practice Address - City:HALLOCK
Practice Address - State:MN
Practice Address - Zip Code:56728
Practice Address - Country:US
Practice Address - Phone:218-843-2205
Practice Address - Fax:218-843-2205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN20471423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AA7257276OtherCOMBINED SUBTURE REGISTER
MN274357400Medicaid
MN274357400Medicaid