Provider Demographics
NPI:1023371440
Name:VANDENBERG, COENRAAD JACOBUS
Entity Type:Individual
Prefix:MR
First Name:COENRAAD
Middle Name:JACOBUS
Last Name:VANDENBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 MILITARY RD E
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98445-1243
Mailing Address - Country:US
Mailing Address - Phone:253-538-2611
Mailing Address - Fax:253-538-4918
Practice Address - Street 1:104 MILITARY RD E
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98445-1243
Practice Address - Country:US
Practice Address - Phone:253-538-2611
Practice Address - Fax:253-538-4918
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-20
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00050052183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist