Provider Demographics
NPI:1003289877
Name:WILSON, STEPHEN (RPH)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:WILSON
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 69
Mailing Address - Street 2:
Mailing Address - City:BANDON
Mailing Address - State:OR
Mailing Address - Zip Code:97411-0069
Mailing Address - Country:US
Mailing Address - Phone:541-347-9864
Mailing Address - Fax:
Practice Address - Street 1:44 MICHIGAN AVE NE
Practice Address - Street 2:
Practice Address - City:BANDON
Practice Address - State:OR
Practice Address - Zip Code:97411-9743
Practice Address - Country:US
Practice Address - Phone:541-347-9457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-03
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6360183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist