=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932140365
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VANS PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2006
-----------------------------------------------------
Last Update Date | 07/09/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 807 NAPIER AVE
-----------------------------------------------------
City | SAINT JOSEPH
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49085-2003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-983-4802
-----------------------------------------------------
Fax | 269-983-7633
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 807 NAPIER AVE
-----------------------------------------------------
City | SAINT JOSEPH
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49085-2003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-983-4802
-----------------------------------------------------
Fax | 269-983-7633
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JAMES BUSSIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 269-983-4802
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 5301009293
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------