Provider Demographics
NPI:1114565702
Name:VAN RYSWYK, JENNIFER MARIE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:VAN RYSWYK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7450 CYPRESS GARDENS BLVD
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33884-6200
Mailing Address - Country:US
Mailing Address - Phone:863-318-0252
Mailing Address - Fax:863-318-0282
Practice Address - Street 1:7450 CYPRESS GARDENS BLVD
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33884-6200
Practice Address - Country:US
Practice Address - Phone:863-318-0252
Practice Address - Fax:863-318-0282
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-15
Last Update Date:2019-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS27167183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist