Provider Demographics
NPI:1477165504
Name:VONDEBUR, CASEY MATTHEW (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:CASEY
Middle Name:MATTHEW
Last Name:VONDEBUR
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2305 W MONROE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-1438
Mailing Address - Country:US
Mailing Address - Phone:217-546-9558
Mailing Address - Fax:
Practice Address - Street 1:2305 W MONROE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-1438
Practice Address - Country:US
Practice Address - Phone:217-546-9558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051299442183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty