Provider Demographics
NPI:1184989097
Name:ANDERSON, RONALD
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1157 COUNTY ROAD R
Mailing Address - Street 2:
Mailing Address - City:NORTH BEND
Mailing Address - State:NE
Mailing Address - Zip Code:68649-2022
Mailing Address - Country:US
Mailing Address - Phone:402-652-8114
Mailing Address - Fax:
Practice Address - Street 1:1157 COUNTY ROAD R
Practice Address - Street 2:
Practice Address - City:NORTH BEND
Practice Address - State:NE
Practice Address - Zip Code:68649-2022
Practice Address - Country:US
Practice Address - Phone:402-652-8114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-06
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE74381835P0018X
IA134001835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA13400OtherIOWA PHARMACIST LICENSE
NE7438OtherNEBRASKA PHARMACIST LICENSE