Provider Demographics
NPI:1780277319
Name:YONCE, IVAN DANE (RPH)
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:DANE
Last Name:YONCE
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:PO BOX 187
Mailing Address - Street 2:
Mailing Address - City:FORK UNION
Mailing Address - State:VA
Mailing Address - Zip Code:23055-0187
Mailing Address - Country:US
Mailing Address - Phone:434-842-3208
Mailing Address - Fax:434-842-1447
Practice Address - Street 1:4316B JAMES MADISON HWY, FORK UNION, VA 23055
Practice Address - Street 2:
Practice Address - City:FORK UNION
Practice Address - State:VA
Practice Address - Zip Code:23055
Practice Address - Country:US
Practice Address - Phone:434-842-3208
Practice Address - Fax:434-842-1447
Is Sole Proprietor?:No
Enumeration Date:2021-02-15
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202007854183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist