Provider Demographics
NPI:1285230144
Name:VANFLEET, JEFFREY (RPH)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:VANFLEET
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 AVALON RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:WI
Mailing Address - Zip Code:53925-1806
Mailing Address - Country:US
Mailing Address - Phone:920-350-2924
Mailing Address - Fax:
Practice Address - Street 1:102 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-2014
Practice Address - Country:US
Practice Address - Phone:920-563-2458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9437-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist