Provider Demographics
NPI:1700160199
Name:ANDERSON, RICHARD KEN (RPH)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:KEN
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 CLUB VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-4405
Mailing Address - Country:US
Mailing Address - Phone:573-449-8330
Mailing Address - Fax:573-449-8173
Practice Address - Street 1:1000 CLUB VILLAGE DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-4405
Practice Address - Country:US
Practice Address - Phone:573-449-8330
Practice Address - Fax:573-449-8173
Is Sole Proprietor?:No
Enumeration Date:2011-10-04
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO044152183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist