Provider Demographics
NPI:1992700819
Name:ANDERSEN, ALAN W (BS PHARM)
Entity type:Individual
Prefix:MR
First Name:ALAN
Middle Name:W
Last Name:ANDERSEN
Suffix:
Gender:M
Credentials:BS PHARM
Other - Prefix:MR
Other - First Name:ALAN
Other - Middle Name:W
Other - Last Name:ANDERSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3498
Mailing Address - Street 2:
Mailing Address - City:INCLINE VILLAGE
Mailing Address - State:NV
Mailing Address - Zip Code:89450-3498
Mailing Address - Country:US
Mailing Address - Phone:775-833-3060
Mailing Address - Fax:775-831-2228
Practice Address - Street 1:898 TANAGER ST
Practice Address - Street 2:IN CARE OF VILLAGE COMPOUNDING PHARMACY
Practice Address - City:INCLINE VILLAGE
Practice Address - State:NV
Practice Address - Zip Code:89451
Practice Address - Country:US
Practice Address - Phone:775-831-1133
Practice Address - Fax:775-831-2228
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3898183500000X
CA24992183500000X
OR8194183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist