Healthcare Provider Details

I. General information

NPI: 1154948438
Provider Name (Legal Business Name): STEPHEN ANDERSON PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2020
Last Update Date: 07/02/2020
Certification Date: 07/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4121 HALIFAX RD
SOUTH BOSTON VA
24592-4833
US

IV. Provider business mailing address

4121 HALIFAX RD
SOUTH BOSTON VA
24592-4833
US

V. Phone/Fax

Practice location:
  • Phone: 434-575-0511
  • Fax: 434-575-1366
Mailing address:
  • Phone: 434-575-0511
  • Fax: 434-575-1366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202209953
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: