Provider Demographics
NPI:1265630776
Name:VLIETSTRA, WENDY KAYE (PHARMD)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:KAYE
Last Name:VLIETSTRA
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 1:1929 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65704-8244
Mailing Address - Country:US
Mailing Address - Phone:417-380-0390
Mailing Address - Fax:
Practice Address - Street 1:101 N BUSINESS 60
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:MO
Practice Address - Zip Code:65704-7101
Practice Address - Country:US
Practice Address - Phone:417-924-8877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-05
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14163183500000X
MO2008012396183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2008012396OtherSTATE BOARD OF PHARMACY