Healthcare Provider Details

I. General information

NPI: 1932308863
Provider Name (Legal Business Name): BRAD ANTHONY DYKSTRA PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2007
Last Update Date: 07/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 S TOWER AVE
CENTRALIA WA
98531-3917
US

IV. Provider business mailing address

417 S TOWER AVE
CENTRALIA WA
98531-3917
US

V. Phone/Fax

Practice location:
  • Phone: 360-736-4433
  • Fax: 360-736-8709
Mailing address:
  • Phone: 360-736-4433
  • Fax: 360-736-8709

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH00070055
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: