Provider Demographics
NPI:1689973794
Name:BYLSMA, RETHA
Entity type:Individual
Prefix:MRS
First Name:RETHA
Middle Name:
Last Name:BYLSMA
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 1:573 CANOE CRK
Mailing Address - Street 2:
Mailing Address - City:GASTON
Mailing Address - State:NC
Mailing Address - Zip Code:27832-9590
Mailing Address - Country:US
Mailing Address - Phone:252-458-4890
Mailing Address - Fax:
Practice Address - Street 1:1825 E 10TH ST
Practice Address - Street 2:
Practice Address - City:ROANOKE RAPIDS
Practice Address - State:NC
Practice Address - Zip Code:27870-4925
Practice Address - Country:US
Practice Address - Phone:252-535-4681
Practice Address - Fax:252-535-5273
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-16
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21569183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist