Provider Demographics
NPI:1639483787
Name:VANDEBERG, ALICIA
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:VANDEBERG
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 1:4611 ROCK NETTLE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-5529
Mailing Address - Country:US
Mailing Address - Phone:210-545-7078
Mailing Address - Fax:
Practice Address - Street 1:17460 IH 35 N
Practice Address - Street 2:
Practice Address - City:SCHERTZ
Practice Address - State:TX
Practice Address - Zip Code:78154-1243
Practice Address - Country:US
Practice Address - Phone:210-651-1649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-31
Last Update Date:2010-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX40805183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist