Provider Demographics
NPI:1255004388
Name:WICKWIRE, GREGORY (PHARMD, RPH)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:
Last Name:WICKWIRE
Suffix:
Gender:M
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3328 SHERWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76901-3529
Mailing Address - Country:US
Mailing Address - Phone:325-947-3677
Mailing Address - Fax:
Practice Address - Street 1:3328 SHERWOOD WAY
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76901-3529
Practice Address - Country:US
Practice Address - Phone:325-947-3677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-26
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX687941835P0018X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist