Healthcare Provider Details

I. General information

NPI: 1184736027
Provider Name (Legal Business Name): VALPARASIO PROFESSIONAL PHARMACY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 11/15/2022
Certification Date: 11/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3540 CALUMET AVE
VALPARAISO IN
46383-2246
US

IV. Provider business mailing address

3540 CALUMET AVE
VALPARAISO IN
46383-2246
US

V. Phone/Fax

Practice location:
  • Phone: 219-462-1484
  • Fax: 219-465-4199
Mailing address:
  • Phone: 219-462-1484
  • Fax: 219-465-4199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number60006597
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number60006597
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number60005539A
License Number StateIN

VIII. Authorized Official

Name: MR. ELTON L VANDERTUIN
Title or Position: OWNER
Credential: RPH
Phone: 219-462-1484