Provider Demographics
NPI:1649870148
Name:WIKSEN, JOHN (PHARMD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:WIKSEN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 E ELEVEN POINT LN
Mailing Address - Street 2:
Mailing Address - City:NIXA
Mailing Address - State:MO
Mailing Address - Zip Code:65714-7931
Mailing Address - Country:US
Mailing Address - Phone:605-595-1959
Mailing Address - Fax:
Practice Address - Street 1:2004 W MARLER LN
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:MO
Practice Address - Zip Code:65721-7661
Practice Address - Country:US
Practice Address - Phone:605-595-1959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD5667183500000X
MN122425183500000X
IA23217183500000X
MO2017044638183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist