Healthcare Provider Details

I. General information

NPI: 1881260651
Provider Name (Legal Business Name): KATHLEEN LYNN VANDENBOS PHARMACY TECHNICIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2021
Last Update Date: 06/02/2021
Certification Date: 05/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 N CENTERVILLE RD
STURGIS MI
49091-1308
US

IV. Provider business mailing address

102 N CENTERVILLE RD
STURGIS MI
49091-1308
US

V. Phone/Fax

Practice location:
  • Phone: 269-651-7818
  • Fax: 269-659-2619
Mailing address:
  • Phone: 269-651-7818
  • Fax: 269-651-7818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number5303006731
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: