Provider Demographics
NPI:1518225036
Name:VANDUYNE, BRENT (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:
Last Name:VANDUYNE
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 1:245 S BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:COAL CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60416-1534
Mailing Address - Country:US
Mailing Address - Phone:815-634-4311
Mailing Address - Fax:815-634-4328
Practice Address - Street 1:245 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:COAL CITY
Practice Address - State:IL
Practice Address - Zip Code:60416-1534
Practice Address - Country:US
Practice Address - Phone:815-634-4311
Practice Address - Fax:815-634-4328
Is Sole Proprietor?:No
Enumeration Date:2012-05-03
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.291887183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist