MEDICARE: DR. ANGELA RENEE VANDER WALL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	5302037940	MI

General Provider Information

NPI Number	:	1962758755
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANGELA RENEE VANDER WALL

Provider Business Mailing Address
First Line	:	1701 PRINCESS LN
Second Line	:
City	:	MUSKEGON
State	:	MI
Zip	:	49445-1739
Country	:	US
Telephone Number	:	231-329-4941
Fax Number	:

Provider Business Practice Location Address
First Line	:	2580 LAKE AVE
Second Line	:
City	:	NORTH MUSKEGON
State	:	MI
Zip	:	49445-3323
Country	:	US
Telephone Number	:	231-744-2401
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/30/2012
Last Update Date	:	07/30/2012

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