MEDICARE: MICAH ANDERSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	10738231-171	UT

General Provider Information

NPI Number	:	1699438168
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICAH ANDERSON

Provider Business Mailing Address
First Line	:	1849 W SUNSET BLVD
Second Line	:
City	:	SAINT GEORGE
State	:	UT
Zip	:	84770-6508
Country	:	US
Telephone Number	:	435-879-5165
Fax Number	:

Provider Business Practice Location Address
First Line	:	1849 W SUNSET BLVD
Second Line	:
City	:	SAINT GEORGE
State	:	UT
Zip	:	84770-6508
Country	:	US
Telephone Number	:	435-879-5165
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/20/2021
Last Update Date	:	10/20/2021

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