Provider Demographics
NPI:1801496062
Name:ANDERSON, GINA AYN
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:AYN
Last Name:ANDERSON
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 1:1503 15TH STREET CIR NE
Mailing Address - Street 2:
Mailing Address - City:KASSON
Mailing Address - State:MN
Mailing Address - Zip Code:55944-1738
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 CROSSROADS DR SW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55902-2183
Practice Address - Country:US
Practice Address - Phone:507-280-9441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN117002183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN117002OtherPHARMACIST