Provider Demographics
NPI:1689945875
Name:VAN DYKE, LORA LEE (PHARM D)
Entity Type:Individual
Prefix:
First Name:LORA
Middle Name:LEE
Last Name:VAN DYKE
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2333 W 57TH ST STE 109
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-5054
Mailing Address - Country:US
Mailing Address - Phone:605-331-3190
Mailing Address - Fax:605-978-3996
Practice Address - Street 1:2333 W 57TH ST STE 109
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-5054
Practice Address - Country:US
Practice Address - Phone:605-331-3190
Practice Address - Fax:605-978-3996
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-19
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA19216183500000X
MN118797183500000X
SD4117183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD4117OtherPHARMACIST LICENSE