Provider Demographics
NPI:1134726904
Name:WICKS, SHELBY BREEANN
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:BREEANN
Last Name:WICKS
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 1:1603 CULVER ST
Mailing Address - Street 2:
Mailing Address - City:COMMERCE
Mailing Address - State:TX
Mailing Address - Zip Code:75428-3422
Mailing Address - Country:US
Mailing Address - Phone:903-886-2867
Mailing Address - Fax:
Practice Address - Street 1:1603 CULVER ST
Practice Address - Street 2:
Practice Address - City:COMMERCE
Practice Address - State:TX
Practice Address - Zip Code:75428-3422
Practice Address - Country:US
Practice Address - Phone:903-886-2867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-05
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX67334183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist