Provider Demographics
NPI:1033673363
Name:VANDERKALLEN, KARA
Entity Type:Individual
Prefix:
First Name:KARA
Middle Name:
Last Name:VANDERKALLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1771 HOLTON RD
Mailing Address - Street 2:
Mailing Address - City:NORTH MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49445-1452
Mailing Address - Country:US
Mailing Address - Phone:231-744-1391
Mailing Address - Fax:
Practice Address - Street 1:1771 HOLTON RD
Practice Address - Street 2:
Practice Address - City:NORTH MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49445-1452
Practice Address - Country:US
Practice Address - Phone:231-744-1391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-31
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302413505183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist