Healthcare Provider Details

I. General information

NPI: 1275459984
Provider Name (Legal Business Name): RYLAN BLAKE WILKENSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2026
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 GA HIGHWAY 247 S
BONAIRE GA
31005-3865
US

IV. Provider business mailing address

510 GA HIGHWAY 247 S
BONAIRE GA
31005-3865
US

V. Phone/Fax

Practice location:
  • Phone: 478-273-6163
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH036272
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: