Provider Demographics
NPI:1639323249
Name:VAN WYK, STEPHANUS JOHANNES
Entity Type:Individual
Prefix:MR
First Name:STEPHANUS
Middle Name:JOHANNES
Last Name:VAN WYK
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 1:502 THOMAS RD
Mailing Address - Street 2:
Mailing Address - City:CAMP HILL
Mailing Address - State:PA
Mailing Address - Zip Code:17011-1260
Mailing Address - Country:US
Mailing Address - Phone:717-763-1133
Mailing Address - Fax:
Practice Address - Street 1:3773 PETERS MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:HALIFAX
Practice Address - State:PA
Practice Address - Zip Code:17032-8605
Practice Address - Country:US
Practice Address - Phone:717-896-9084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-10
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARPI001089183500000X
PARP441444183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist