Provider Demographics
NPI:1952867467
Name:WILCZEK, TREVOR PATRICK
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:PATRICK
Last Name:WILCZEK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 W ADMIRE AVE
Mailing Address - Street 2:
Mailing Address - City:KINGFISHER
Mailing Address - State:OK
Mailing Address - Zip Code:73750-2609
Mailing Address - Country:US
Mailing Address - Phone:405-375-3202
Mailing Address - Fax:405-375-6739
Practice Address - Street 1:119 W ADMIRE AVE
Practice Address - Street 2:
Practice Address - City:KINGFISHER
Practice Address - State:OK
Practice Address - Zip Code:73750-2609
Practice Address - Country:US
Practice Address - Phone:405-375-3202
Practice Address - Fax:405-375-6739
Is Sole Proprietor?:No
Enumeration Date:2019-02-20
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14013183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist