Provider Demographics
NPI:1962950071
Name:ANDERSON, CAROLYN M (RPH)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:M
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 1:3558 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-4508
Mailing Address - Country:US
Mailing Address - Phone:304-748-6290
Mailing Address - Fax:304-748-6291
Practice Address - Street 1:3558 MAIN ST
Practice Address - Street 2:
Practice Address - City:WEIRTON
Practice Address - State:WV
Practice Address - Zip Code:26062-4508
Practice Address - Country:US
Practice Address - Phone:304-748-6290
Practice Address - Fax:304-748-6291
Is Sole Proprietor?:No
Enumeration Date:2016-09-17
Last Update Date:2016-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0003881183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist