Healthcare Provider Details

I. General information

NPI: 1093624322
Provider Name (Legal Business Name): MATTHEW ROBERT ANDERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 STADIUM MALL DR
WEST LAFAYETTE IN
47907-2091
US

IV. Provider business mailing address

712 FRANKLIN LN
LINDENHURST IL
60046-4985
US

V. Phone/Fax

Practice location:
  • Phone: 847-804-6351
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number45024376A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: