MEDICARE: LUKE ASHTON WYCKOFF PHARM. D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	0202215805	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0202215805	OTHER	VA	VIRGINIA BOARD OF PHARMACY

General Provider Information

NPI Number	:	1568935948
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LUKE ASHTON WYCKOFF PHARM. D.

Provider Business Mailing Address
First Line	:	304 LONG CREEK LN
Second Line	:
City	:	HAMPTON
State	:	VA
Zip	:	23664-1923
Country	:	US
Telephone Number	:	757-651-5833
Fax Number	:

Provider Business Practice Location Address
First Line	:	304 LONG CREEK LN
Second Line	:
City	:	HAMPTON
State	:	VA
Zip	:	23664-1923
Country	:	US
Telephone Number	:	757-651-5833
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/08/2019
Last Update Date	:	01/08/2019

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