Provider Demographics
NPI:1710420153
Name:VALPARAISO PROFESSIONAL PHARMACY,P.C.
Entity Type:Organization
Organization Name:VALPARAISO PROFESSIONAL PHARMACY,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ELTON
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:VANDER TUIN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:219-462-1485
Mailing Address - Street 1:2101 ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-2747
Mailing Address - Country:US
Mailing Address - Phone:219-462-1485
Mailing Address - Fax:219-465-4199
Practice Address - Street 1:2101 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2747
Practice Address - Country:US
Practice Address - Phone:219-462-1485
Practice Address - Fax:219-465-4199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-01
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy