Provider Demographics
NPI:1083744437
Name:VANDENBROEK, LAURA KRISTINE (PHARMD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:KRISTINE
Last Name:VANDENBROEK
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6475 DELANEY FERRY EXTENSION
Mailing Address - Street 2:
Mailing Address - City:VERSAILLES
Mailing Address - State:KY
Mailing Address - Zip Code:40383
Mailing Address - Country:US
Mailing Address - Phone:859-879-0012
Mailing Address - Fax:859-881-5975
Practice Address - Street 1:1401 KEENE RD
Practice Address - Street 2:
Practice Address - City:NICHOLASVILLE
Practice Address - State:KY
Practice Address - Zip Code:40356
Practice Address - Country:US
Practice Address - Phone:859-881-3652
Practice Address - Fax:859-881-5975
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY012171183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist