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General NPI Number Information
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NPI Number | 1730192188
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Entity Type | Individual
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Provider Name | MRS. JACQUELINE CAROLE VANDER VELDEN
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Gender | Female
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Dates
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Enumeration Date | 08/15/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 301 N MICHIGAN ST
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City | PLYMOUTH
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State | IN
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Zip | 46563-1735
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Country | US
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Telephone | 574-936-3167
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Fax |
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Provider Business Mailing Address
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Address Line | 17375 2B RD
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City | WALKERTON
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State | IN
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Zip | 46574-8620
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Country | US
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Telephone | 574-586-3922
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 2601475A
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License Number State | IN
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