Provider Demographics
NPI:1295334217
Name:ANDERSEN, MARY JANE
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:ANDERSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11575 BIG ISLAND RD
Mailing Address - Street 2:
Mailing Address - City:ASHBY
Mailing Address - State:MN
Mailing Address - Zip Code:56309-4598
Mailing Address - Country:US
Mailing Address - Phone:218-205-5310
Mailing Address - Fax:
Practice Address - Street 1:3300 HWY 210 W
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537
Practice Address - Country:US
Practice Address - Phone:218-739-5559
Practice Address - Fax:218-739-3983
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN115556183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist