Provider Demographics
NPI:1417257395
Name:VANDENBOOM, COREY (RPH)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:VANDENBOOM
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10105 224TH ST E
Mailing Address - Street 2:
Mailing Address - City:GRAHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98338-9190
Mailing Address - Country:US
Mailing Address - Phone:253-847-7634
Mailing Address - Fax:253-847-7635
Practice Address - Street 1:10105 224TH ST E
Practice Address - Street 2:
Practice Address - City:GRAHAM
Practice Address - State:WA
Practice Address - Zip Code:98338-9190
Practice Address - Country:US
Practice Address - Phone:253-847-7634
Practice Address - Fax:253-847-7635
Is Sole Proprietor?:No
Enumeration Date:2010-10-26
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00065649183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist