Provider Demographics
NPI:1932140365
Name:VANS PHARMACY INC
Entity Type:Organization
Organization Name:VANS PHARMACY INC
Other - Org Name:VANS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:BUSSIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-983-4802
Mailing Address - Street 1:807 NAPIER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-2003
Mailing Address - Country:US
Mailing Address - Phone:269-983-4802
Mailing Address - Fax:269-983-7633
Practice Address - Street 1:807 NAPIER AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-2003
Practice Address - Country:US
Practice Address - Phone:269-983-4802
Practice Address - Fax:269-983-7633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010092933336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2125058OtherPK
2125058OtherPK