Provider Demographics
NPI:1982712964
Name:VAN DUSSELDORP, ANGELA MARIE (R PH)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:MARIE
Last Name:VAN DUSSELDORP
Suffix:
Gender:F
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 N EISENHOWER AVE
Mailing Address - Street 2:
Mailing Address - City:MASON CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50401-1525
Mailing Address - Country:US
Mailing Address - Phone:641-422-5630
Mailing Address - Fax:641-422-5599
Practice Address - Street 1:910 N EISENHOWER AVE
Practice Address - Street 2:
Practice Address - City:MASON CITY
Practice Address - State:IA
Practice Address - Zip Code:50401-1525
Practice Address - Country:US
Practice Address - Phone:641-422-5630
Practice Address - Fax:641-422-5599
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA18617183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist