Provider Demographics
NPI:1467720235
Name:VANDYCK, MARTHA JANE (DPH)
Entity Type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:JANE
Last Name:VANDYCK
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9325 POPLAR AVE
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-7906
Mailing Address - Country:US
Mailing Address - Phone:901-309-1609
Mailing Address - Fax:901-309-1067
Practice Address - Street 1:9325 POPLAR AVE
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-7906
Practice Address - Country:US
Practice Address - Phone:901-309-1609
Practice Address - Fax:901-309-1067
Is Sole Proprietor?:No
Enumeration Date:2011-12-08
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5890183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist