=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649870148
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN WIKSEN PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2020
-----------------------------------------------------
Last Update Date | 10/26/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2004 W MARLER LN
-----------------------------------------------------
City | OZARK
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65721-7661
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-595-1959
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 725 E ELEVEN POINT LN
-----------------------------------------------------
City | NIXA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65714-7931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-595-1959
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 5667
-----------------------------------------------------
License Number State | SD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 122425
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 23217
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 2017044638
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------