Provider Demographics
NPI:1902055874
Name:WICKWIRE, MYLLA JAYLYNN (PHARMD)
Entity Type:Individual
Prefix:
First Name:MYLLA
Middle Name:JAYLYNN
Last Name:WICKWIRE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:MYLLA
Other - Middle Name:JAYLYNN
Other - Last Name:OWNBEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:8921 BOBWHITE RD
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-8456
Mailing Address - Country:US
Mailing Address - Phone:405-467-4208
Mailing Address - Fax:
Practice Address - Street 1:5252 N MERIDIAN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-2178
Practice Address - Country:US
Practice Address - Phone:405-880-8888
Practice Address - Fax:405-992-0561
Is Sole Proprietor?:No
Enumeration Date:2008-09-15
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14083183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist