Provider Demographics
NPI:1962703637
Name:VANDENBERG, RICHARD JOHN (RPH)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:JOHN
Last Name:VANDENBERG
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1112 S M ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-3654
Mailing Address - Country:US
Mailing Address - Phone:253-572-7753
Mailing Address - Fax:253-272-9315
Practice Address - Street 1:1112 S M ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-3654
Practice Address - Country:US
Practice Address - Phone:253-572-7753
Practice Address - Fax:253-272-9315
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-10
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00007877183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist