Provider Demographics
NPI:1104110220
Name:ANDERSON, DALE WAYNE (RPH)
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:WAYNE
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 1:4160 TOWN CTR
Mailing Address - Street 2:T-1861
Mailing Address - City:SHERMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75092-2567
Mailing Address - Country:US
Mailing Address - Phone:903-892-4416
Mailing Address - Fax:903-892-4416
Practice Address - Street 1:4160 TOWN CTR
Practice Address - Street 2:T-1861
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75092-2567
Practice Address - Country:US
Practice Address - Phone:903-892-4416
Practice Address - Fax:903-892-4416
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-06
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX27701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist