Provider Demographics
NPI:1922382506
Name:VANDELIST, MARK J (RPH)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:VANDELIST
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2190 W DRAKE RD
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-1488
Mailing Address - Country:US
Mailing Address - Phone:970-484-5841
Mailing Address - Fax:
Practice Address - Street 1:2190 W DRAKE RD
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526-1488
Practice Address - Country:US
Practice Address - Phone:970-484-5841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-30
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO18555183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist