Healthcare Provider Details

I. General information

NPI: 1558553230
Provider Name (Legal Business Name): JEROME V VALE PHARMACIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2007
Last Update Date: 08/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1061 VANDERBURGH DR
VALPARAISO IN
46385-6166
US

IV. Provider business mailing address

1061 VANDERBURGH DR
VALPARAISO IN
46385-6166
US

V. Phone/Fax

Practice location:
  • Phone: 219-548-2095
  • Fax:
Mailing address:
  • Phone: 219-548-2095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26011759
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: