Provider Demographics
NPI:1831581172
Name:ANDERSON, SUSAN (PHARM D)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4005 VINEWOOD LANE N
Mailing Address - Street 2:WALGREENS 02767
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55442
Mailing Address - Country:US
Mailing Address - Phone:763-553-9731
Mailing Address - Fax:763-553-9144
Practice Address - Street 1:4005 VINEWOOD LANE N
Practice Address - Street 2:WALGREENS 02767
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55442
Practice Address - Country:US
Practice Address - Phone:763-553-9731
Practice Address - Fax:763-553-9144
Is Sole Proprietor?:No
Enumeration Date:2015-02-24
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN121755183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN121755OtherMN BOARD OF PHARMACY LICENSE NUMBER