Healthcare Provider Details

I. General information

NPI: 1184786782
Provider Name (Legal Business Name): ANDERSON PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 09/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 S 2ND
HALLOCK MN
56728
US

IV. Provider business mailing address

BX 99 115 S 2ND
HALLOCK MN
56728
US

V. Phone/Fax

Practice location:
  • Phone: 218-843-2205
  • Fax: 218-843-2205
Mailing address:
  • Phone: 218-843-2205
  • Fax: 218-843-2205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2047142
License Number StateMN

VIII. Authorized Official

Name: MR. HAROLD G ANDERSON
Title or Position: OWNER RPH
Credential: RPH
Phone: 218-843-2205