Provider Demographics
NPI:1780619106
Name:ANDERSON, LARRY DEAN (RPH)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:DEAN
Last Name:ANDERSON
Suffix:
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 1:2114 N ELDRED RD
Mailing Address - Street 2:
Mailing Address - City:CHINO VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86323-5212
Mailing Address - Country:US
Mailing Address - Phone:928-771-5364
Mailing Address - Fax:928-771-5502
Practice Address - Street 1:1003 WILLOW CREEK RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1641
Practice Address - Country:US
Practice Address - Phone:928-771-5364
Practice Address - Fax:928-771-5502
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8973183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ8973OtherAZ PHARMACIST LICENSE