Provider Demographics
NPI:1487968285
Name:VAN DER MERWE, JOHANNES DAWID (RPH)
Entity type:Individual
Prefix:MR
First Name:JOHANNES
Middle Name:DAWID
Last Name:VAN DER MERWE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 BROADWAY
Mailing Address - Street 2:APT 2A
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-5210
Mailing Address - Country:US
Mailing Address - Phone:207-385-5735
Mailing Address - Fax:
Practice Address - Street 1:302 MAIN ST
Practice Address - Street 2:
Practice Address - City:OLD TOWN
Practice Address - State:ME
Practice Address - Zip Code:04468-1535
Practice Address - Country:US
Practice Address - Phone:207-827-8021
Practice Address - Fax:207-827-3829
Is Sole Proprietor?:No
Enumeration Date:2010-08-04
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR5830183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist