Provider Demographics
NPI:1063060234
Name:ANDERSON, MARIAH (RPH)
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:
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 1:40794 OLYMPIA DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313-5350
Mailing Address - Country:US
Mailing Address - Phone:586-707-0067
Mailing Address - Fax:
Practice Address - Street 1:15250 24 MILE RD
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48042-5817
Practice Address - Country:US
Practice Address - Phone:586-677-1108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-29
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302411517183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist