Provider Demographics
NPI:1093579955
Name:WILSON, MAKENNA GEORGIANNA (RPH)
Entity Type:Individual
Prefix:
First Name:MAKENNA
Middle Name:GEORGIANNA
Last Name:WILSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:768 S 15TH ST UNIT B
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-2136
Mailing Address - Country:US
Mailing Address - Phone:240-320-3539
Mailing Address - Fax:
Practice Address - Street 1:1601 NAAMANS RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19810-3020
Practice Address - Country:US
Practice Address - Phone:302-246-1933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-12
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEA1-0016009183500000X
PARP458296183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist