Provider Demographics
NPI:1174126403
Name:VAN, CHRISTOPHER E
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:E
Last Name:VAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 W I 30
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75043-5702
Mailing Address - Country:US
Mailing Address - Phone:214-303-5414
Mailing Address - Fax:214-303-6785
Practice Address - Street 1:555 W I 30
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75043-5702
Practice Address - Country:US
Practice Address - Phone:972-303-5414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38684183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist