Provider Demographics
NPI:1073116877
Name:WILSON, JESSE (PHARMD)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3612 SE LEE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73501-8451
Mailing Address - Country:US
Mailing Address - Phone:580-355-6400
Mailing Address - Fax:580-355-0451
Practice Address - Street 1:3612 SE LEE BLVD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73501-8451
Practice Address - Country:US
Practice Address - Phone:580-355-6400
Practice Address - Fax:580-355-0451
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15439183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist