Provider Demographics
NPI:1215122981
Name:ANDERSON, LYLE WILLARD (RPH)
Entity type:Individual
Prefix:MR
First Name:LYLE
Middle Name:WILLARD
Last Name:ANDERSON
Suffix:
Gender:
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 2ND ST
Mailing Address - Street 2:MICKLESEN DRUG INC
Mailing Address - City:HUDSON
Mailing Address - State:MI
Mailing Address - Zip Code:54016
Mailing Address - Country:US
Mailing Address - Phone:715-386-3344
Mailing Address - Fax:715-386-5198
Practice Address - Street 1:530 2ND ST
Practice Address - Street 2:MICKLESEN DRUG INC
Practice Address - City:HUDSON
Practice Address - State:MI
Practice Address - Zip Code:54016
Practice Address - Country:US
Practice Address - Phone:715-386-3344
Practice Address - Fax:715-386-5198
Is Sole Proprietor?:No
Enumeration Date:2007-09-06
Last Update Date:2025-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1098244183500000X
WI10443040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1098244OtherMN LICENSE
WI10443040OtherPHARMACIST LICENSE