Provider Demographics
NPI:1013068493
Name:VALLANDINGHAM, JACK ROBERT (RPH)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:ROBERT
Last Name:VALLANDINGHAM
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 1:100 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SIGOURNEY
Mailing Address - State:IA
Mailing Address - Zip Code:52591-1414
Mailing Address - Country:US
Mailing Address - Phone:641-622-3184
Mailing Address - Fax:641-622-1054
Practice Address - Street 1:100 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SIGOURNEY
Practice Address - State:IA
Practice Address - Zip Code:52591-1414
Practice Address - Country:US
Practice Address - Phone:641-622-3184
Practice Address - Fax:641-622-1054
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA13888183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0181529Medicaid
1607324OtherNABP