Healthcare Provider Details

I. General information

NPI: 1376635425
Provider Name (Legal Business Name): MARK C ANDERSON RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 2ND ST MICKLESON DRUG INC
HUDSON WI
54016
US

IV. Provider business mailing address

715 LAKE DR
STILLWATER MN
55082
US

V. Phone/Fax

Practice location:
  • Phone: 715-386-3344
  • Fax: 715-386-5198
Mailing address:
  • Phone: 651-439-5295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number10955040
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number1142750
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: