Provider Demographics
NPI:1740987502
Name:VANVUUREN, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:VANVUUREN
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 1:1951 S MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX CENTER
Mailing Address - State:IA
Mailing Address - Zip Code:51250-1173
Mailing Address - Country:US
Mailing Address - Phone:712-722-3516
Mailing Address - Fax:
Practice Address - Street 1:1951 S MAIN AVE
Practice Address - Street 2:
Practice Address - City:SIOUX CENTER
Practice Address - State:IA
Practice Address - Zip Code:51250-1173
Practice Address - Country:US
Practice Address - Phone:712-722-3516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA18283183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAIA18283Medicaid