Healthcare Provider Details

I. General information

NPI: 1205164779
Provider Name (Legal Business Name): DWAIN DAVIS WILKERSON PHARM.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2009
Last Update Date: 05/27/2022
Certification Date: 05/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 COCHRANE CIR UNIT MEDDAC
FORT CARSON CO
80913-4604
US

IV. Provider business mailing address

7651 BUCKEYE TREE LN
COLORADO SPRINGS CO
80927-4023
US

V. Phone/Fax

Practice location:
  • Phone: 719-526-7000
  • Fax:
Mailing address:
  • Phone: 719-651-2090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202207917
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number21939
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPHA.0021939
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: