1558647065 NPI number — MRS. LORI KIMBERLEY VANDERMEER RPH

Table of content: MRS. LORI KIMBERLEY VANDERMEER RPH (NPI 1558647065)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558647065 NPI number — MRS. LORI KIMBERLEY VANDERMEER RPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANDERMEER
Provider First Name:
LORI
Provider Middle Name:
KIMBERLEY
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RPH
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:
1558647065
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/28/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3047 W ALBAIN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONROE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48161-9553
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-457-4326
Provider Business Mailing Address Fax Number:
734-457-4326

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
484 S TELEGRAPH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48161-1612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-240-2954
Provider Business Practice Location Address Fax Number:
734-240-2960
Provider Enumeration Date:
10/28/2011

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: 183500000X , with the licence number:  5302411096 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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