Provider Demographics
NPI:1407178270
Name:VANWYKE, ROGER ALAN (RPH)
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:ALAN
Last Name:VANWYKE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 S CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48911-3858
Mailing Address - Country:US
Mailing Address - Phone:517-393-6804
Mailing Address - Fax:517-393-2846
Practice Address - Street 1:5400 S CEDAR ST
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911-3858
Practice Address - Country:US
Practice Address - Phone:517-393-6804
Practice Address - Fax:517-393-2846
Is Sole Proprietor?:No
Enumeration Date:2010-02-22
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302020044183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist