Provider Demographics
NPI:1164009569
Name:WYRICK, BRYAN K
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:K
Last Name:WYRICK
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 1:215 PIEDMONT PL
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-4176
Mailing Address - Country:US
Mailing Address - Phone:434-797-3479
Mailing Address - Fax:434-797-3479
Practice Address - Street 1:215 PIEDMONT PL
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-4176
Practice Address - Country:US
Practice Address - Phone:434-797-3479
Practice Address - Fax:434-797-3479
Is Sole Proprietor?:No
Enumeration Date:2021-03-24
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202211761183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0202211761OtherVA PHARMACY LICENSE