Provider Demographics
NPI:1366045619
Name:VANDERPOEL, MICHAEL PATE
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PATE
Last Name:VANDERPOEL
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 1:1070 WETLAND DR
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75033-1635
Mailing Address - Country:US
Mailing Address - Phone:214-793-3365
Mailing Address - Fax:
Practice Address - Street 1:1025 W TRINITY MILLS RD STE 120
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75006-1384
Practice Address - Country:US
Practice Address - Phone:800-273-3455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38097183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist