Provider Demographics
NPI:1972625408
Name:VANDENBERG, BONNIE C (RP)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:C
Last Name:VANDENBERG
Suffix:
Gender:F
Credentials:RP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7328 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68134-6829
Mailing Address - Country:US
Mailing Address - Phone:402-391-2659
Mailing Address - Fax:
Practice Address - Street 1:7328 MAPLE ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68134-6829
Practice Address - Country:US
Practice Address - Phone:402-391-2659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE11712183500000X
MO043041183500000X
KS1-11548183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist