Provider Demographics
NPI:1003449851
Name:WYLIE, RACHEL OCTAVIA
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:OCTAVIA
Last Name:WYLIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1226 MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IN
Mailing Address - Zip Code:47620-1358
Mailing Address - Country:US
Mailing Address - Phone:618-218-6502
Mailing Address - Fax:
Practice Address - Street 1:1226 MULBERRY ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IN
Practice Address - Zip Code:47620-1358
Practice Address - Country:US
Practice Address - Phone:618-218-6502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-20
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051301509183500000X
IN26028287A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN26028287AMedicaid