Provider Demographics
NPI:1295333565
Name:WILKES, SAMANTHA (PHARMD)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:WILKES
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:POWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:702 W CHESTNUT ST STE 103
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-2814
Mailing Address - Country:US
Mailing Address - Phone:309-807-5160
Mailing Address - Fax:309-517-0899
Practice Address - Street 1:702 W CHESTNUT ST STE 103
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-2814
Practice Address - Country:US
Practice Address - Phone:309-807-5160
Practice Address - Fax:309-517-0899
Is Sole Proprietor?:No
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.294409183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist