Provider Demographics
NPI:1053442681
Name:WILSON, BRIAN EUGENE (RPH)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:EUGENE
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 1:14919 STATE ROUTE 1078 S
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:KY
Mailing Address - Zip Code:42420-9256
Mailing Address - Country:US
Mailing Address - Phone:270-860-1997
Mailing Address - Fax:270-546-2275
Practice Address - Street 1:517 N GREEN ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420-2947
Practice Address - Country:US
Practice Address - Phone:270-827-1897
Practice Address - Fax:270-827-1809
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO15893183500000X
KY12268183500000X
FLPS39753183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist