Provider Demographics
NPI:1700303104
Name:VANDEVENDER, JAMES WALDO (RPH)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:WALDO
Last Name:VANDEVENDER
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:PO BOX 141
Mailing Address - Street 2:
Mailing Address - City:DE KALB
Mailing Address - State:MS
Mailing Address - Zip Code:39328-0141
Mailing Address - Country:US
Mailing Address - Phone:601-743-5738
Mailing Address - Fax:
Practice Address - Street 1:14916 HWY 16 WEST
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:MS
Practice Address - Zip Code:39328
Practice Address - Country:US
Practice Address - Phone:601-743-2917
Practice Address - Fax:601-743-4455
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-25
Last Update Date:2017-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-07553183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist