=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477875771
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RONALD D VREDENBURG RPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2010
-----------------------------------------------------
Last Update Date | 02/28/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2355 US HIGHWAY 23 S
-----------------------------------------------------
City | ALPENA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49707-4553
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-356-8418
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11539 SAMPSON RD
-----------------------------------------------------
City | OSSINEKE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49766-9758
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-471-5593
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 5302026056
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------