Provider Demographics
NPI:1073258109
Name:WILSON, KEVIN G (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:G
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:PO BOX 788
Mailing Address - Street 2:
Mailing Address - City:MULLENS
Mailing Address - State:WV
Mailing Address - Zip Code:25882-0788
Mailing Address - Country:US
Mailing Address - Phone:304-294-5447
Mailing Address - Fax:304-294-5714
Practice Address - Street 1:224 HOWARD AVE
Practice Address - Street 2:
Practice Address - City:MULLENS
Practice Address - State:WV
Practice Address - Zip Code:25882-1421
Practice Address - Country:US
Practice Address - Phone:304-294-5447
Practice Address - Fax:304-294-5714
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-03
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0006379183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist