Provider Demographics
NPI:1629203278
Name:VANWORMER, JEFF (R PH)
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:
Last Name:VANWORMER
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 N 5TH ST
Mailing Address - Street 2:P.O. BOX 547
Mailing Address - City:ROSCOMMON
Mailing Address - State:MI
Mailing Address - Zip Code:48653-9329
Mailing Address - Country:US
Mailing Address - Phone:989-275-5600
Mailing Address - Fax:989-275-4707
Practice Address - Street 1:412 N 5TH ST
Practice Address - Street 2:
Practice Address - City:ROSCOMMON
Practice Address - State:MI
Practice Address - Zip Code:48653-9329
Practice Address - Country:US
Practice Address - Phone:989-275-5600
Practice Address - Fax:989-275-4707
Is Sole Proprietor?:No
Enumeration Date:2009-05-27
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302029215183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist