Healthcare Provider Details

I. General information

NPI: 1558762385
Provider Name (Legal Business Name): BRANDON JAE ANDERSON PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2014
Last Update Date: 09/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2011 E FRY BLVD
SIERRA VISTA AZ
85635-2753
US

IV. Provider business mailing address

2011 E FRY BLVD
SIERRA VISTA AZ
85635-2753
US

V. Phone/Fax

Practice location:
  • Phone: 520-458-3388
  • Fax: 520-459-5724
Mailing address:
  • Phone: 520-458-3388
  • Fax: 520-459-5724

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberS020830
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: