Provider Demographics
NPI:1255489522
Name:ANDERSON, BRUCE R (PPH)
Entity type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:R
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2161 HERON AVE N
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-5314
Mailing Address - Country:US
Mailing Address - Phone:651-773-0634
Mailing Address - Fax:
Practice Address - Street 1:530 2ND ST
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-1512
Practice Address - Country:US
Practice Address - Phone:715-386-3344
Practice Address - Fax:715-386-5198
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11051-040183500000X
MN114361-0183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI5106275OtherNAPB
WI33003000Medicaid
WI33003000Medicaid