Provider Demographics
NPI:1003416504
Name:WYCHE, MARK ALAN
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:WYCHE
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 1:8107 GOV RITCHIE HWY
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:MD
Mailing Address - Zip Code:21122-6917
Mailing Address - Country:US
Mailing Address - Phone:410-689-1508
Mailing Address - Fax:
Practice Address - Street 1:8107 GOV RITCHIE HWY
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:MD
Practice Address - Zip Code:21122-6917
Practice Address - Country:US
Practice Address - Phone:410-689-1508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD097785183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist