Provider Demographics
NPI:1033530290
Name:WILKONSKI-LARSON, RENEE
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:WILKONSKI-LARSON
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:PO BOX 7543
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59904-0543
Mailing Address - Country:US
Mailing Address - Phone:406-370-9877
Mailing Address - Fax:
Practice Address - Street 1:55 1ST AVE EN
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-4001
Practice Address - Country:US
Practice Address - Phone:406-370-9877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-13
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT3744183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist