Provider Demographics
NPI:1124399241
Name:VANN, VONCENIA
Entity Type:Individual
Prefix:
First Name:VONCENIA
Middle Name:
Last Name:VANN
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 1:1225 E RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GRIFFITH
Mailing Address - State:IN
Mailing Address - Zip Code:46319-1461
Mailing Address - Country:US
Mailing Address - Phone:219-838-4280
Mailing Address - Fax:
Practice Address - Street 1:5424 JACKSON ST
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-1447
Practice Address - Country:US
Practice Address - Phone:219-884-4372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-20
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26020090A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist