Provider Demographics
NPI:1861706954
Name:WICKER, STEPHEN (RPH)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:WICKER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 284
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:ME
Mailing Address - Zip Code:04927-0284
Mailing Address - Country:US
Mailing Address - Phone:207-426-6005
Mailing Address - Fax:207-426-6007
Practice Address - Street 1:1167 MAIN ST.
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:ME
Practice Address - Zip Code:04927-3906
Practice Address - Country:US
Practice Address - Phone:207-426-6005
Practice Address - Fax:207-426-6007
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-30
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEADV28941183500000X
MA22682183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1609216498Medicaid