Provider Demographics
NPI:1356983308
Name:WINGATE, OLIVIA BROOKS (PHARMD)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:BROOKS
Last Name:WINGATE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2553 STRATHSPEY CV
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-7718
Mailing Address - Country:US
Mailing Address - Phone:901-482-4463
Mailing Address - Fax:
Practice Address - Street 1:8700 W TRAIL LAKE DR STE 205
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38125-8205
Practice Address - Country:US
Practice Address - Phone:901-309-1404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-11
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN43415183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist