Provider Demographics
NPI:1083028336
Name:VAN DER LINDE, CORNELIUS
Entity Type:Individual
Prefix:MR
First Name:CORNELIUS
Middle Name:
Last Name:VAN DER LINDE
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 1:45527 MEADOW LAKE DR
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-4998
Mailing Address - Country:US
Mailing Address - Phone:760-285-1249
Mailing Address - Fax:
Practice Address - Street 1:45527 MEADOW LAKE DR
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-4998
Practice Address - Country:US
Practice Address - Phone:760-285-1249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-15
Last Update Date:2014-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53983183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist