Provider Demographics
NPI:1346842010
Name:VANDEVENDER, ROY OSWALD
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:OSWALD
Last Name:VANDEVENDER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 187
Mailing Address - Street 2:
Mailing Address - City:DE KALB
Mailing Address - State:MS
Mailing Address - Zip Code:39328-0187
Mailing Address - Country:US
Mailing Address - Phone:601-692-7922
Mailing Address - Fax:
Practice Address - Street 1:1002 W BEACON ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:MS
Practice Address - Zip Code:39350-3204
Practice Address - Country:US
Practice Address - Phone:601-656-5312
Practice Address - Fax:601-656-5312
Is Sole Proprietor?:No
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-07808183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist