Provider Demographics
NPI:1184807760
Name:ANDERSON, MAURICE ROSS (RPH)
Entity type:Individual
Prefix:MR
First Name:MAURICE
Middle Name:ROSS
Last Name:ANDERSON
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 1:293 STATE ROUTE 104 STE D
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-2946
Mailing Address - Country:US
Mailing Address - Phone:315-343-4371
Mailing Address - Fax:315-343-2407
Practice Address - Street 1:293 STATE ROUTE 104 STE D
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-2946
Practice Address - Country:US
Practice Address - Phone:315-343-4371
Practice Address - Fax:315-343-2407
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-06
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY25706183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist