Healthcare Provider Details

I. General information

NPI: 1952460222
Provider Name (Legal Business Name): LYNDA ANDERSON C.PH.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 S. MAIN ST.
KENT CITY MI
49330
US

IV. Provider business mailing address

1861 20 MILE RD
KENT CITY MI
49330-9735
US

V. Phone/Fax

Practice location:
  • Phone: 616-678-5380
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number290101040755371
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: