Provider Demographics
NPI:1396010237
Name:VANDENBUSSCHE, KEN
Entity type:Individual
Prefix:
First Name:KEN
Middle Name:
Last Name:VANDENBUSSCHE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 37
Mailing Address - Street 2:
Mailing Address - City:KEKAHA
Mailing Address - State:HI
Mailing Address - Zip Code:96752-0037
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4300 NUHOU ST
Practice Address - Street 2:
Practice Address - City:LIHUE
Practice Address - State:HI
Practice Address - Zip Code:96766-8002
Practice Address - Country:US
Practice Address - Phone:808-241-4009
Practice Address - Fax:808-241-4006
Is Sole Proprietor?:No
Enumeration Date:2012-03-10
Last Update Date:2012-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPH1745183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist