Provider Demographics
NPI:1427825199
Name:ANDERSON, SHAUN (PHARMD)
Entity type:Individual
Prefix:
First Name:SHAUN
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3555 COUNTY LINE RD
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN GROVE
Mailing Address - State:MO
Mailing Address - Zip Code:65711-2843
Mailing Address - Country:US
Mailing Address - Phone:417-349-2668
Mailing Address - Fax:866-291-1699
Practice Address - Street 1:500 E 19TH ST STE D
Practice Address - Street 2:
Practice Address - City:MOUNTAIN GROVE
Practice Address - State:MO
Practice Address - Zip Code:65711-1115
Practice Address - Country:US
Practice Address - Phone:417-349-2668
Practice Address - Fax:866-291-1699
Is Sole Proprietor?:No
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019024422183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist