Provider Demographics
NPI:1780170480
Name:VANDERHOLM, THOMAS (PHARMD)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:
Last Name:VANDERHOLM
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5453 HWY 2
Mailing Address - Street 2:
Mailing Address - City:PRIEST RIVER
Mailing Address - State:ID
Mailing Address - Zip Code:83856
Mailing Address - Country:US
Mailing Address - Phone:208-448-1633
Mailing Address - Fax:
Practice Address - Street 1:5453 HIGHWAY 2
Practice Address - Street 2:
Practice Address - City:PRIEST RIVER
Practice Address - State:ID
Practice Address - Zip Code:83856
Practice Address - Country:US
Practice Address - Phone:208-448-1633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-05
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP8050183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist