Provider Demographics
NPI:1033099817
Name:WICKHAM, DAYTON
Entity type:Individual
Prefix:
First Name:DAYTON
Middle Name:
Last Name:WICKHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26522 GALLO DR
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74019-7543
Mailing Address - Country:US
Mailing Address - Phone:918-720-4718
Mailing Address - Fax:
Practice Address - Street 1:2217 NW 23RD ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73107-2403
Practice Address - Country:US
Practice Address - Phone:405-521-0807
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-03
Last Update Date:2025-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK21079183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist