Provider Demographics
NPI:1487127932
Name:VAN AUSDALL, STEPHEN LUKE (PHARMD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:LUKE
Last Name:VAN AUSDALL
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 E WENDOVER AVE
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-1205
Mailing Address - Country:US
Mailing Address - Phone:336-832-3630
Mailing Address - Fax:
Practice Address - Street 1:201 E WENDOVER AVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1205
Practice Address - Country:US
Practice Address - Phone:336-832-3630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC26902183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist