MEDICARE: BRAD ANTHONY DYKSTRA PHARMD

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	PH00070055	WA

General Provider Information

NPI Number	:	1932308863
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRAD ANTHONY DYKSTRA PHARMD

Provider Business Mailing Address
First Line	:	417 S TOWER AVE
Second Line	:
City	:	CENTRALIA
State	:	WA
Zip	:	98531-3917
Country	:	US
Telephone Number	:	360-736-4433
Fax Number	:	360-736-8709

Provider Business Practice Location Address
First Line	:	417 S TOWER AVE
Second Line	:
City	:	CENTRALIA
State	:	WA
Zip	:	98531-3917
Country	:	US
Telephone Number	:	360-736-4433
Fax Number	:	360-736-8709

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

Provider Enumeration Date	:	07/11/2007
Last Update Date	:	07/11/2007

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