MEDICARE: MR. JOHN HASTINGS VANDEL R. PH.

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	183500000X	Pharmacist	1435	WY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1435	OTHER	WY	PHARMACY LICENSE

General Provider Information

NPI Number	:	1477591592
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN HASTINGS VANDEL R. PH.

Provider Business Mailing Address
First Line	:	2041 MAIN ST
Second Line	:
City	:	TORRINGTON
State	:	WY
Zip	:	82240-2708
Country	:	US
Telephone Number	:	307-766-6120
Fax Number	:	307-766-2953

Provider Business Practice Location Address
First Line	:	2041 MAIN ST
Second Line	:
City	:	TORRINGTON
State	:	WY
Zip	:	82240-2708
Country	:	US
Telephone Number	:	307-766-6120
Fax Number	:	307-766-2953

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

Provider Enumeration Date	:	06/02/2006
Last Update Date	:	07/08/2007

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