Provider Demographics
NPI:1114080348
Name:VANDER BROEK, ALLYSON KAY (PHARMD)
Entity Type:Individual
Prefix:MS
First Name:ALLYSON
Middle Name:KAY
Last Name:VANDER BROEK
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 1:11668 N CARSON WAY
Mailing Address - Street 2:
Mailing Address - City:GOLD RIVER
Mailing Address - State:CA
Mailing Address - Zip Code:95670-8106
Mailing Address - Country:US
Mailing Address - Phone:916-858-0901
Mailing Address - Fax:
Practice Address - Street 1:2210 SUNRISE BLVD
Practice Address - Street 2:
Practice Address - City:RANCHO CORDOVA
Practice Address - State:CA
Practice Address - Zip Code:95670
Practice Address - Country:US
Practice Address - Phone:916-638-0214
Practice Address - Fax:916-638-2513
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH41808183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist