Provider Demographics
NPI:1154765451
Name:WICK, ROLAND THEODORE
Entity type:Individual
Prefix:
First Name:ROLAND
Middle Name:THEODORE
Last Name:WICK
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 1:2701 HIGHWAY 18 W
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57747-6604
Mailing Address - Country:US
Mailing Address - Phone:605-745-4681
Mailing Address - Fax:605-745-4813
Practice Address - Street 1:2701 HIGHWAY 18 W
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:SD
Practice Address - Zip Code:57747-6604
Practice Address - Country:US
Practice Address - Phone:605-745-4681
Practice Address - Fax:605-745-4813
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-17
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD3584183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist