Provider Demographics
NPI:1457659088
Name:VAN DER LINDE, PETRUS GIJSBERTUS (B PHARM)
Entity Type:Individual
Prefix:MR
First Name:PETRUS
Middle Name:GIJSBERTUS
Last Name:VAN DER LINDE
Suffix:
Gender:M
Credentials:B PHARM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 1ST ST
Mailing Address - Street 2:
Mailing Address - City:BLACK MOUNTAIN
Mailing Address - State:NC
Mailing Address - Zip Code:28711-3103
Mailing Address - Country:US
Mailing Address - Phone:828-290-5585
Mailing Address - Fax:
Practice Address - Street 1:540 NC HIGHWAY 9
Practice Address - Street 2:
Practice Address - City:BLACK MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:28711-3829
Practice Address - Country:US
Practice Address - Phone:828-669-2216
Practice Address - Fax:828-669-0419
Is Sole Proprietor?:No
Enumeration Date:2011-03-07
Last Update Date:2024-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20880183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0116616Medicaid