Provider Demographics
NPI:1235434267
Name:WICKIZER, STEPHEN WESLEY (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:WESLEY
Last Name:WICKIZER
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 1:1204 TIMESVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SIGNAL MTN
Mailing Address - State:TN
Mailing Address - Zip Code:37377-2106
Mailing Address - Country:US
Mailing Address - Phone:423-883-3283
Mailing Address - Fax:
Practice Address - Street 1:1204 TIMESVILLE RD
Practice Address - Street 2:
Practice Address - City:SIGNAL MTN
Practice Address - State:TN
Practice Address - Zip Code:37377-2106
Practice Address - Country:US
Practice Address - Phone:423-883-3283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-23
Last Update Date:2011-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4031183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist