Provider Demographics
NPI:1093354847
Name:WILSON, SALLY (RPH)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:WILSON
Other - Last Name:PERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:210 HIBRITEN WAY
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-2224
Mailing Address - Country:US
Mailing Address - Phone:863-670-7618
Mailing Address - Fax:
Practice Address - Street 1:7450 CYPRESS GARDENS BLVD
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33884-6200
Practice Address - Country:US
Practice Address - Phone:863-318-0252
Practice Address - Fax:863-318-0282
Is Sole Proprietor?:No
Enumeration Date:2019-12-26
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS24455183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist