MEDICARE: DR. AMY M VANDENBERG PHARMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1835P1300X	Psychiatric Pharmacist	9958	SC

General Provider Information

NPI Number	:	1275524399
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AMY M VANDENBERG PHARMD

Provider Business Mailing Address
First Line	:	425 HARRODS LN
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29412-4355
Country	:	US
Telephone Number	:	843-792-0179
Fax Number	:

Provider Business Practice Location Address
First Line	:	67 PRESIDENT ST
Second Line	:	IOP 3 NORTH ROOM 339
City	:	CHARLESTON
State	:	SC
Zip	:	29403-5712
Country	:	US
Telephone Number	:	843-792-0179
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/31/2005
Last Update Date	:	07/08/2007

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