Provider Demographics
NPI:1750898854
Name:ANDERSON, VERTUS
Entity type:Individual
Prefix:
First Name:VERTUS
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 1:1207 PRINCETON AVE
Mailing Address - Street 2:
Mailing Address - City:VERMILLION
Mailing Address - State:SD
Mailing Address - Zip Code:57069-7232
Mailing Address - Country:US
Mailing Address - Phone:605-624-4106
Mailing Address - Fax:605-624-4139
Practice Address - Street 1:1207 PRINCETON AVE
Practice Address - Street 2:
Practice Address - City:VERMILLION
Practice Address - State:SD
Practice Address - Zip Code:57069-7232
Practice Address - Country:US
Practice Address - Phone:605-624-4106
Practice Address - Fax:605-624-4139
Is Sole Proprietor?:No
Enumeration Date:2018-01-10
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR4564183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist