Provider Demographics
NPI:1447685706
Name:VAN WIG, DALE WARREN (R PH)
Entity type:Individual
Prefix:MR
First Name:DALE
Middle Name:WARREN
Last Name:VAN WIG
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:256 SUNDANCE LN
Mailing Address - Street 2:APT. 516
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82072-8717
Mailing Address - Country:US
Mailing Address - Phone:307-766-4546
Mailing Address - Fax:
Practice Address - Street 1:544 N. THIRD ST
Practice Address - Street 2:PHARMACY
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070
Practice Address - Country:US
Practice Address - Phone:307-745-4224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-05
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3619TL183500000X
MO044929183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist