Provider Demographics
NPI:1124384912
Name:VAN DE WIEL, STEPHEN WALLACE
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:WALLACE
Last Name:VAN DE WIEL
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 1:1425 E BUSINESS HIGHWAY 151
Mailing Address - Street 2:
Mailing Address - City:PLATTEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53818-3842
Mailing Address - Country:US
Mailing Address - Phone:608-348-6577
Mailing Address - Fax:608-348-5909
Practice Address - Street 1:1425 E BUSINESS HIGHWAY 151
Practice Address - Street 2:
Practice Address - City:PLATTEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53818-3842
Practice Address - Country:US
Practice Address - Phone:608-348-6577
Practice Address - Fax:608-348-5909
Is Sole Proprietor?:No
Enumeration Date:2012-04-05
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9046-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist