Healthcare Provider Details

I. General information

NPI: 1407867906
Provider Name (Legal Business Name): VERNON ANDERSEN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

341 W BETHALTO DR
BETHALTO IL
62010-1779
US

IV. Provider business mailing address

341 W BETHALTO DR
BETHALTO IL
62010-1779
US

V. Phone/Fax

Practice location:
  • Phone: 618-377-5356
  • Fax: 618-377-0159
Mailing address:
  • Phone: 618-377-5356
  • Fax: 618-377-0159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number054014647
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. VERNON EUGENE ANDERSEN
Title or Position: PRESIDENT
Credential: RPH
Phone: 618-377-5356