Provider Demographics
NPI:1881260651
Name:VANDENBOS, KATHLEEN LYNN (PHARMACY TECHNICIAN)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:LYNN
Last Name:VANDENBOS
Suffix:
Gender:F
Credentials:PHARMACY TECHNICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 N CENTERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:STURGIS
Mailing Address - State:MI
Mailing Address - Zip Code:49091-1308
Mailing Address - Country:US
Mailing Address - Phone:269-651-7818
Mailing Address - Fax:269-651-7818
Practice Address - Street 1:102 N CENTERVILLE RD
Practice Address - Street 2:
Practice Address - City:STURGIS
Practice Address - State:MI
Practice Address - Zip Code:49091-1308
Practice Address - Country:US
Practice Address - Phone:269-651-7818
Practice Address - Fax:269-659-2619
Is Sole Proprietor?:No
Enumeration Date:2021-06-02
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303006731183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician