Provider Demographics
NPI:1861788804
Name:ANDERSON, THEA BRINK (RPH)
Entity type:Individual
Prefix:
First Name:THEA
Middle Name:BRINK
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20237 COUNTY ROAD 14 NW
Mailing Address - Street 2:
Mailing Address - City:BIG LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55309-9501
Mailing Address - Country:US
Mailing Address - Phone:763-263-0464
Mailing Address - Fax:
Practice Address - Street 1:1447 E 7TH ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-4666
Practice Address - Country:US
Practice Address - Phone:763-271-1101
Practice Address - Fax:763-271-1101
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-28
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN113235183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist