Provider Demographics
NPI:1356618268
Name:VANDER KOOI, AMY GRAVES (PHARMD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:GRAVES
Last Name:VANDER KOOI
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8618 ELLIS CT
Mailing Address - Street 2:
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80005-5874
Mailing Address - Country:US
Mailing Address - Phone:303-912-1979
Mailing Address - Fax:
Practice Address - Street 1:570 US HIGHWAY 287
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020-1732
Practice Address - Country:US
Practice Address - Phone:720-274-0379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-20
Last Update Date:2011-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO16339183500000X
TN12107183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist