Provider Demographics
NPI:1932308863
Name:DYKSTRA, BRAD ANTHONY (PHARMD)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:ANTHONY
Last Name:DYKSTRA
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 S TOWER AVE
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-3917
Mailing Address - Country:US
Mailing Address - Phone:360-736-4433
Mailing Address - Fax:360-736-8709
Practice Address - Street 1:417 S TOWER AVE
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-3917
Practice Address - Country:US
Practice Address - Phone:360-736-4433
Practice Address - Fax:360-736-8709
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-11
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00070055183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist