Provider Demographics
NPI:1497902548
Name:DE VISSER, TANYA E MINKEVICH (RPH)
Entity Type:Individual
Prefix:MRS
First Name:TANYA
Middle Name:E MINKEVICH
Last Name:DE VISSER
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:MISS
Other - First Name:TANYA
Other - Middle Name:ELIZABETH
Other - Last Name:MINKEVICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:4746 FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64112-1113
Mailing Address - Country:US
Mailing Address - Phone:816-213-3336
Mailing Address - Fax:
Practice Address - Street 1:4023 S NOLAND RD
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64055-6507
Practice Address - Country:US
Practice Address - Phone:816-254-1366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-20
Last Update Date:2016-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO044737183500000X
KS1-12737183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist