Provider Demographics
NPI:1376628396
Name:VAN'S CORNER DRUG
Entity Type:Organization
Organization Name:VAN'S CORNER DRUG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:J
Authorized Official - Last Name:VANDELIST
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:920-324-5211
Mailing Address - Street 1:401 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WAUPUN
Mailing Address - State:WI
Mailing Address - Zip Code:53963-2161
Mailing Address - Country:US
Mailing Address - Phone:920-324-5211
Mailing Address - Fax:920-324-4360
Practice Address - Street 1:401 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WAUPUN
Practice Address - State:WI
Practice Address - Zip Code:53963-2161
Practice Address - Country:US
Practice Address - Phone:920-324-5211
Practice Address - Fax:920-324-4360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7714-042183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI5114373OtherNCPDP
WI33226400Medicaid
WI33226400Medicaid