Provider Demographics
NPI:1558661082
Name:VONBERGEN, ERIC WALTER JR (BS)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:WALTER
Last Name:VONBERGEN
Suffix:JR
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5411 FANTAIL DR
Mailing Address - Street 2:
Mailing Address - City:ELDERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21784-8935
Mailing Address - Country:US
Mailing Address - Phone:410-549-1069
Mailing Address - Fax:
Practice Address - Street 1:8775 CLOUDLEAP CT
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-3044
Practice Address - Country:US
Practice Address - Phone:301-596-5027
Practice Address - Fax:301-596-4857
Is Sole Proprietor?:No
Enumeration Date:2010-11-01
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD07325183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist