Provider Demographics
NPI:1992086904
Name:ANDERSON, HAILEE (PHARM D)
Entity type:Individual
Prefix:
First Name:HAILEE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-3227
Mailing Address - Country:US
Mailing Address - Phone:307-856-4934
Mailing Address - Fax:307-856-4943
Practice Address - Street 1:1200 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-3227
Practice Address - Country:US
Practice Address - Phone:307-856-4934
Practice Address - Fax:307-856-4943
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-02
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3490183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist