Provider Demographics
NPI:1336712785
Name:VAN WYCK, OLIVIA (PHARMD)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:VAN WYCK
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 VARNEY RD
Mailing Address - Street 2:
Mailing Address - City:JERICHO
Mailing Address - State:VT
Mailing Address - Zip Code:05465-3008
Mailing Address - Country:US
Mailing Address - Phone:802-999-9819
Mailing Address - Fax:
Practice Address - Street 1:9 SUSIE WILSON RD
Practice Address - Street 2:
Practice Address - City:ESSEX JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05452-2814
Practice Address - Country:US
Practice Address - Phone:802-872-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-22
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT033.0134545183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist