1417131665 NPI number — DR. CORI K VANDEVENDER PHARM.D

Table of content: DR. CORI K VANDEVENDER PHARM.D (NPI 1417131665)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417131665 NPI number — DR. CORI K VANDEVENDER PHARM.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANDEVENDER
Provider First Name:
CORI
Provider Middle Name:
K
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHARM.D
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417131665
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
27040 US HIGHWAY 98
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAPHNE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36526-4824
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-259-0962
Provider Business Mailing Address Fax Number:
251-621-5754

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
523 4TH AVE SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RED BAY
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35582
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-356-9204
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/24/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 183500000X , with the licence number: 15255 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)