Provider Demographics
NPI:1306122262
Name:VANDERMAUSE, MARK STEPHEN (BS PHARMACY RPH)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:STEPHEN
Last Name:VANDERMAUSE
Suffix:
Gender:M
Credentials:BS PHARMACY RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N4086 COUNTY ROAD C
Mailing Address - Street 2:
Mailing Address - City:FREEDOM
Mailing Address - State:WI
Mailing Address - Zip Code:54913-7759
Mailing Address - Country:US
Mailing Address - Phone:920-832-4065
Mailing Address - Fax:
Practice Address - Street 1:2412 CROOKS AVE
Practice Address - Street 2:
Practice Address - City:KAUKAUNA
Practice Address - State:WI
Practice Address - Zip Code:54130-3914
Practice Address - Country:US
Practice Address - Phone:920-759-9165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-24
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9249-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist