Provider Demographics
NPI:1003409392
Name:WILSON, DAVID (RPH)
Entity Type:Individual
Prefix:
First Name:DAVID
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 1:348 NW CAPITAL DR
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64086-4723
Mailing Address - Country:US
Mailing Address - Phone:816-600-2200
Mailing Address - Fax:
Practice Address - Street 1:348 NW CAPITAL DR
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64086-4723
Practice Address - Country:US
Practice Address - Phone:816-600-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-17
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005041001183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist