Provider Demographics
NPI:1881011153
Name:WICK, JEFFREY (RPH)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:WICK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 HIGHWAY 10 S
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56304-1250
Mailing Address - Country:US
Mailing Address - Phone:320-253-5373
Mailing Address - Fax:320-253-4985
Practice Address - Street 1:501 HIGHWAY 10 S
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56304-1250
Practice Address - Country:US
Practice Address - Phone:320-253-5373
Practice Address - Fax:320-253-4985
Is Sole Proprietor?:No
Enumeration Date:2014-03-25
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN112894183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist