Provider Demographics
NPI:1609360338
Name:VAN DYKE, ALAN E (RPH)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:E
Last Name:VAN DYKE
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 1:1522 APPLEGATE ST
Mailing Address - Street 2:
Mailing Address - City:PHILOMATH
Mailing Address - State:OR
Mailing Address - Zip Code:97370-9327
Mailing Address - Country:US
Mailing Address - Phone:541-609-1606
Mailing Address - Fax:
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-3504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-16
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH0006215183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist