Provider Demographics
NPI:1528416849
Name:WICKLINE, CRYSTAL (PHARMD)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:WICKLINE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5606 RESERVOIR RD
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45801-9737
Mailing Address - Country:US
Mailing Address - Phone:419-371-3566
Mailing Address - Fax:
Practice Address - Street 1:730 W MARKET ST
Practice Address - Street 2:PHARMACY
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45801-4602
Practice Address - Country:US
Practice Address - Phone:419-226-9025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-26
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03330932183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist