Provider Demographics
NPI:1043627540
Name:ANDERSON, REBECCA
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 WOOD CREEK CT
Mailing Address - Street 2:
Mailing Address - City:WHITE OAK
Mailing Address - State:TX
Mailing Address - Zip Code:75693-3914
Mailing Address - Country:US
Mailing Address - Phone:903-758-0323
Mailing Address - Fax:903-758-3546
Practice Address - Street 1:701 W MARSHALL AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-6218
Practice Address - Country:US
Practice Address - Phone:903-758-0323
Practice Address - Fax:903-758-3546
Is Sole Proprietor?:No
Enumeration Date:2014-07-16
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35603183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist