Provider Demographics
NPI:1538893698
Name:VAN DYKE, MADELEINE SIMONE
Entity type:Individual
Prefix:
First Name:MADELEINE
Middle Name:SIMONE
Last Name:VAN DYKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17870 COUNTY RD S
Mailing Address - Street 2:
Mailing Address - City:ALVORDTON
Mailing Address - State:OH
Mailing Address - Zip Code:43501-9743
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2244 COLLINGWOOD BLVD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43620-1147
Practice Address - Country:US
Practice Address - Phone:567-318-3891
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-14
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH034421861835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist