Provider Demographics
NPI:1497532352
Name:WILKINSON, MADDISYN
Entity Type:Individual
Prefix:
First Name:MADDISYN
Middle Name:
Last Name:WILKINSON
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 1:625 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:AR
Mailing Address - Zip Code:71730-4003
Mailing Address - Country:US
Mailing Address - Phone:318-789-7854
Mailing Address - Fax:
Practice Address - Street 1:1402 PERSHING HWY
Practice Address - Street 2:
Practice Address - City:SMACKOVER
Practice Address - State:AR
Practice Address - Zip Code:71762-2300
Practice Address - Country:US
Practice Address - Phone:870-725-2220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-13
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPNT.048768183500000X
ARPI23178183500000X
ARPD16706183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist