Provider Demographics
NPI:1952520462
Name:VAN LARE, JONATHAN VICTOR (PHARM D)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:VICTOR
Last Name:VAN LARE
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1393 MOY AVENUE
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:N8X 4S5
Mailing Address - Country:CA
Mailing Address - Phone:519-253-0605
Mailing Address - Fax:
Practice Address - Street 1:22777 W 11 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-2152
Practice Address - Country:US
Practice Address - Phone:248-358-9160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302035070183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist