Active NPI
Mark Gruen Anderson, RPH
- Pharmacist
- Plymouth, WI
National Provider Identifier
1629334073
On this page
OIG exclusion record
The HHS Office of Inspector General’s List of Excluded Individuals/Entities (LEIE) contains a record with this NPI:
- Section 1128b(4) exclusion effective May 20, 2025.
Key facts
NPPES NPI Registry- Primary specialty
- Pharmacist
- License
- 9189-40
- Practice address
- 2615 Eastern Ave
Plymouth, WI 53073-4270 - Phone
- (920) 892-4182
- NPI assigned
- Apr 10, 2012
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacist | 183500000X | 9189-40 | WI | Primary |
Addresses
Primary practice location
2615 Eastern Ave
Plymouth, WI 53073-4270
Mailing address
626 Thomas St
Fond Du Lac, WI 54935-3022
Phone (920) 892-4182
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- HHS exclusion list flag
- Flagged The directory lists this NPI on an HHS exclusion list.
- Credentials
- Registered Pharmacist
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 9189-40 | WI | MD | Pharmacist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1334016000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1334016000000",
"number": "1629334073",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "626 THOMAS ST",
"city": "FOND DU LAC",
"state": "WI",
"postal_code": "549353022",
"telephone_number": "920-892-4182"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2615 EASTERN AVE",
"city": "PLYMOUTH",
"state": "WI",
"postal_code": "530734270",
"telephone_number": "920-892-4182"
}
],
"practiceLocations": [],
"basic": {
"last_name": "ANDERSON",
"first_name": "MARK",
"middle_name": "GRUEN",
"name_prefix": "Mr.",
"credential": "RPH",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2012-04-10",
"last_updated": "2012-04-10",
"status": "A"
},
"taxonomies": [
{
"code": "183500000X",
"taxonomy_group": "",
"desc": "Pharmacist",
"state": "WI",
"license": "9189-40",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Plymouth, WI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 10, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; OIG LEIE.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.