Provider Demographics
NPI:1619577608
Name:WILKERSON-ADE, MIRANDA SHEA (PHARMD)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:SHEA
Last Name:WILKERSON-ADE
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 1:5010 KOALA DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-8833
Mailing Address - Country:US
Mailing Address - Phone:870-262-7176
Mailing Address - Fax:
Practice Address - Street 1:2405 S CARAWAY RD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-6208
Practice Address - Country:US
Practice Address - Phone:870-203-7055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR14124183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist