Provider Demographics
NPI:1174384242
Name:WILKINS, THOMAS MATTHEW
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:MATTHEW
Last Name:WILKINS
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 1:221 SWORDFISH DR
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72802-2494
Mailing Address - Country:US
Mailing Address - Phone:479-886-8025
Mailing Address - Fax:
Practice Address - Street 1:2109 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-2757
Practice Address - Country:US
Practice Address - Phone:479-498-9540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD11977183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist