Healthcare Provider Details

I. General information

NPI: 1699082453
Provider Name (Legal Business Name): RENEE ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2010
Last Update Date: 09/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6535 PAW PAW AVE
COLOMA MI
49038-8805
US

IV. Provider business mailing address

6535 PAW PAW AVE
COLOMA MI
49038-8805
US

V. Phone/Fax

Practice location:
  • Phone: 269-468-3858
  • Fax:
Mailing address:
  • Phone: 269-468-3858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302036179
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: