Provider Demographics
NPI:1346871027
Name:VANDAHM, JACK WARREN (PHARMD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:WARREN
Last Name:VANDAHM
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1402 W 14 MILE RD
Mailing Address - Street 2:
Mailing Address - City:CLAWSON
Mailing Address - State:MI
Mailing Address - Zip Code:48017-1499
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1402 W 14 MILE RD
Practice Address - Street 2:
Practice Address - City:CLAWSON
Practice Address - State:MI
Practice Address - Zip Code:48017-1499
Practice Address - Country:US
Practice Address - Phone:248-435-7314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-30
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302042373183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist