Provider Demographics
NPI:1083184162
Name:WILSON, TRISTAN
Entity Type:Individual
Prefix:
First Name:TRISTAN
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 1:1119 E TULSA AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS
Mailing Address - State:OK
Mailing Address - Zip Code:74347-7055
Mailing Address - Country:US
Mailing Address - Phone:918-868-6162
Mailing Address - Fax:
Practice Address - Street 1:1119 E TULSA AVE
Practice Address - Street 2:
Practice Address - City:KANSAS
Practice Address - State:OK
Practice Address - Zip Code:74347-7055
Practice Address - Country:US
Practice Address - Phone:918-868-6162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-30
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15459183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist