MEDICARE: T'QUOMAS KNOX VANBERGEN PHARM.D.

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	22899	NC
2	183500000X	Pharmacist	14091	SC
3	183500000X	Pharmacist	057311	NY

General Provider Information

NPI Number	:	1992137525
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	T'QUOMAS KNOX VANBERGEN PHARM.D.

Provider Business Mailing Address
First Line	:	748 SEDGEFIELD RD
Second Line	:	APT E
City	:	CHARLOTTE
State	:	NC
Zip	:	28209-1245
Country	:	US
Telephone Number	:	518-496-9944
Fax Number	:

Provider Business Practice Location Address
First Line	:	14125 STEELE CREEK RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28273-3968
Country	:	US
Telephone Number	:	704-504-8199
Fax Number	:

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

Provider Enumeration Date	:	08/06/2013
Last Update Date	:	08/06/2013

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