Provider Demographics
NPI:1457134934
Name:ANDERSON, KAIDE MICHAEL
Entity Type:Individual
Prefix:
First Name:KAIDE
Middle Name:MICHAEL
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 1:943 PULASKI HWY
Mailing Address - Street 2:
Mailing Address - City:HAVRE DE GRACE
Mailing Address - State:MD
Mailing Address - Zip Code:21078-2601
Mailing Address - Country:US
Mailing Address - Phone:410-939-4282
Mailing Address - Fax:
Practice Address - Street 1:943 PULASKI HWY
Practice Address - Street 2:
Practice Address - City:HAVRE DE GRACE
Practice Address - State:MD
Practice Address - Zip Code:21078-2601
Practice Address - Country:US
Practice Address - Phone:410-939-4282
Practice Address - Fax:410-939-4284
Is Sole Proprietor?:No
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDT26394183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist