Provider Demographics
NPI:1245353234
Name:JOLLY, ANDERSON S JR (RPH)
Entity type:Individual
Prefix:MR
First Name:ANDERSON
Middle Name:S
Last Name:JOLLY
Suffix:JR
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 1:12923 SE 95TH WAY
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98056-2435
Mailing Address - Country:US
Mailing Address - Phone:253-952-2803
Mailing Address - Fax:253-952-0387
Practice Address - Street 1:12923 SE 95TH WAY
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98056-2435
Practice Address - Country:US
Practice Address - Phone:253-952-2803
Practice Address - Fax:253-952-0387
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00019615183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist