Provider Demographics
NPI:1619592086
Name:PROSSER, VICKY LYNN
Entity Type:Individual
Prefix:
First Name:VICKY
Middle Name:LYNN
Last Name:PROSSER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 58TH CT
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-2817
Mailing Address - Country:US
Mailing Address - Phone:515-210-6490
Mailing Address - Fax:
Practice Address - Street 1:1001 73RD ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50324-1311
Practice Address - Country:US
Practice Address - Phone:515-274-6359
Practice Address - Fax:515-277-6168
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-11
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA17743183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist