Provider Demographics
NPI:1043381205
Name:WILSON, CHARLES EDWARD (RPH)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:EDWARD
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 167
Mailing Address - Street 2:18 CHURCH ST
Mailing Address - City:ENGLEWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37329-0167
Mailing Address - Country:US
Mailing Address - Phone:423-887-7293
Mailing Address - Fax:423-887-7022
Practice Address - Street 1:18 CHURCH ST
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:TN
Practice Address - Zip Code:37329-3301
Practice Address - Country:US
Practice Address - Phone:423-887-7293
Practice Address - Fax:423-887-7022
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2837183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist