Provider Demographics
NPI:1518371269
Name:VANDERBOOM, JOAN (RPH)
Entity Type:Individual
Prefix:MS
First Name:JOAN
Middle Name:
Last Name:VANDERBOOM
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6817 ESCONDIDO DR APT A
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-3150
Mailing Address - Country:US
Mailing Address - Phone:479-530-7173
Mailing Address - Fax:
Practice Address - Street 1:6817 ESCONDIDO DR APT A
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-3150
Practice Address - Country:US
Practice Address - Phone:479-530-7173
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-19
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX42386183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist