Provider Demographics
NPI:1073100558
Name:WILSON, JAMES DAVIS
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:DAVIS
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 CROSSGATES BLVD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-2602
Mailing Address - Country:US
Mailing Address - Phone:601-825-8660
Mailing Address - Fax:601-825-6983
Practice Address - Street 1:335 CROSSGATES BLVD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-2602
Practice Address - Country:US
Practice Address - Phone:601-825-8660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-30
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-08635183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist