Provider Demographics
NPI:1992137525
Name:VANBERGEN, T'QUOMAS KNOX (PHARMD)
Entity type:Individual
Prefix:
First Name:T'QUOMAS
Middle Name:KNOX
Last Name:VANBERGEN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:748 SEDGEFIELD RD
Mailing Address - Street 2:APT E
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-1245
Mailing Address - Country:US
Mailing Address - Phone:518-496-9944
Mailing Address - Fax:
Practice Address - Street 1:14125 STEELE CREEK RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-3968
Practice Address - Country:US
Practice Address - Phone:704-504-8199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-06
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC22899183500000X
SC14091183500000X
NY057311183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist