Provider Demographics
NPI:1033491402
Name:WILKINSON, BRUCE ALAN
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:ALAN
Last Name:WILKINSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 US HIGHWAY 331 S
Mailing Address - Street 2:
Mailing Address - City:DEFUNIAK SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32435-3383
Mailing Address - Country:US
Mailing Address - Phone:850-951-9882
Mailing Address - Fax:
Practice Address - Street 1:1103 US HIGHWAY 331 S
Practice Address - Street 2:
Practice Address - City:DEFUNIAK SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32435-3383
Practice Address - Country:US
Practice Address - Phone:850-951-9882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-12
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS25388183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL031927900Medicaid