Healthcare Provider Details

I. General information

NPI: 1285230144
Provider Name (Legal Business Name): JEFFREY VANFLEET RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2020
Last Update Date: 12/21/2025
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 S MAIN ST
FORT ATKINSON WI
53538-2014
US

IV. Provider business mailing address

210 AVALON RD
COLUMBUS WI
53925-1806
US

V. Phone/Fax

Practice location:
  • Phone: 920-563-2458
  • Fax:
Mailing address:
  • Phone: 920-350-2924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number9437-40
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: