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General NPI Number Information
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NPI Number | 1124384912
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Entity Type | Individual
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Provider Name | STEPHEN WALLACE VAN DE WIEL
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Gender | Male
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Dates
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Enumeration Date | 04/05/2012
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Last Update Date | 04/05/2012
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Provider Practice Location Address
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Address Line | 1425 E BUSINESS HIGHWAY 151
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City | PLATTEVILLE
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State | WI
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Zip | 53818-3842
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Country | US
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Telephone | 608-348-6577
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Fax | 608-348-5909
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Provider Business Mailing Address
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Address Line | 1425 E BUSINESS HIGHWAY 151
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City | PLATTEVILLE
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State | WI
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Zip | 53818-3842
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Country | US
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Telephone | 608-348-6577
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Fax | 608-348-5909
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 9046-40
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License Number State | WI
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