Basic Information
| Provider Information | |||||||||
| NPI: | 1508052655 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | ETHAN | ||||||||
| MiddleName: | AARON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHARM.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 16592 PILGRIM CT | ||||||||
| Address2: | |||||||||
| City: | LATHROP | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953308976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095454275 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3801 MIRANDA AVE | ||||||||
| Address2: | |||||||||
| City: | PALO ALTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 943041207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6504935000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2007 | ||||||||
| LastUpdateDate: | 05/03/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 60121 | CA | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.