Individual
ETHAN VANDERSAND
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
400A W CARPENTER ST, JERSEYVILLE, IL 62052-2522
(618) 498-6461
Mailing address
RR 1 BOX 128, WHITE HALL, IL 62092-9713
(618) 498-6461
Taxonomy
Speciality
Code
Description
License number
State
183500000X
Pharmacist
Primary
051-289033
IL
Other
Enumeration date
09/10/2012
Last updated
09/10/2012
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