Provider Demographics
NPI:1083088876
Name:WILSON, HEATHER
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05676-1553
Mailing Address - Country:US
Mailing Address - Phone:802-244-8458
Mailing Address - Fax:802-244-1882
Practice Address - Street 1:80 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:VT
Practice Address - Zip Code:05676-1553
Practice Address - Country:US
Practice Address - Phone:802-244-8458
Practice Address - Fax:802-244-1882
Is Sole Proprietor?:No
Enumeration Date:2015-11-17
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT3629183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist