Provider Demographics
NPI:1366023988
Name:KLAASSEN, VICKY LYNNE (CPHT)
Entity Type:Individual
Prefix:
First Name:VICKY
Middle Name:LYNNE
Last Name:KLAASSEN
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 BROOKMEADOW NORTH LN SW APT 2
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-3282
Mailing Address - Country:US
Mailing Address - Phone:616-334-1309
Mailing Address - Fax:
Practice Address - Street 1:3999 ALPINE AVE NW
Practice Address - Street 2:
Practice Address - City:COMSTOCK PARK
Practice Address - State:MI
Practice Address - Zip Code:49321-8350
Practice Address - Country:US
Practice Address - Phone:616-784-1619
Practice Address - Fax:616-784-2454
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-15
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI183700000X
MI5303002666183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician