Healthcare Provider Details

I. General information

NPI: 1902104177
Provider Name (Legal Business Name): MARK AARON ANDERSON R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2011
Last Update Date: 03/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 W COLUMBIA ST
FARMINGTON MO
63640-2902
US

IV. Provider business mailing address

1010 W COLUMBIA ST
FARMINGTON MO
63640-2902
US

V. Phone/Fax

Practice location:
  • Phone: 573-218-6756
  • Fax: 573-218-6762
Mailing address:
  • Phone: 573-218-6756
  • Fax: 573-218-6762

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2000174704
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: