Healthcare Provider Details

I. General information

NPI: 1407178270
Provider Name (Legal Business Name): ROGER ALAN VANWYKE R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2010
Last Update Date: 02/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 S CEDAR ST
LANSING MI
48911-3858
US

IV. Provider business mailing address

5400 S CEDAR ST
LANSING MI
48911-3858
US

V. Phone/Fax

Practice location:
  • Phone: 517-393-6804
  • Fax: 517-393-2846
Mailing address:
  • Phone: 517-393-6804
  • Fax: 517-393-2846

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302020044
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: