Provider Demographics
NPI:1033646732
Name:VANGEERSDAELE, DAVID ALLAN (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:ALLAN
Last Name:VANGEERSDAELE
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:763 STRAITS TPKE STOP
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06795-3318
Mailing Address - Country:US
Mailing Address - Phone:860-274-7461
Mailing Address - Fax:860-274-6124
Practice Address - Street 1:763 STRAITS TPKE STOP & SHOP #657
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:CT
Practice Address - Zip Code:06795-3318
Practice Address - Country:US
Practice Address - Phone:860-274-7461
Practice Address - Fax:860-274-6124
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-12
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0005564183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT409257OtherNABP