Provider Demographics
NPI:1912902024
Name:CC ANDERSON PC
Entity Type:Organization
Organization Name:CC ANDERSON PC
Other - Org Name:MEDICAP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:M
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:515-795-4252
Mailing Address - Street 1:411 ANNEX RD
Mailing Address - Street 2:
Mailing Address - City:MADRID
Mailing Address - State:IA
Mailing Address - Zip Code:50156-1471
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:411 ANNEX RD
Practice Address - Street 2:
Practice Address - City:MADRID
Practice Address - State:IA
Practice Address - Zip Code:50156-1471
Practice Address - Country:US
Practice Address - Phone:515-795-4252
Practice Address - Fax:515-795-4255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-15
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA274333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0298539Medicaid
ND21514Medicaid
MD005817300Medicaid
NE10025316200Medicaid
MN20056411500Medicaid
SD8530970Medicaid
1621627OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MI370458100Medicaid
IN200321290AMedicaid
ND21514Medicaid
IA4912890001Medicare NSC