Basic Information
| Provider Information | |||||||||
| NPI: | 1699055848 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANDENBERG | ||||||||
| FirstName: | KATHRYN | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 287 | ||||||||
| Address2: | |||||||||
| City: | BETHEL | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995590287 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075436652 | ||||||||
| FaxNumber: | 9075436306 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 CHIEF EDDIE HOFFMAN HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | BETHEL | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995590287 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075436652 | ||||||||
| FaxNumber: | 9075436306 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2011 | ||||||||
| LastUpdateDate: | 08/19/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 1956 | AK | Y | Pharmacy Service Providers | Pharmacist | 183500000X | 16231-40 | WI | N | Pharmacy Service Providers | Pharmacist |
No ID Information.