Provider Demographics
NPI:1114094885
Name:MASON, PHILLIP WILSON (RPH)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:WILSON
Last Name:MASON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:294 RAINWATER RD
Mailing Address - Street 2:
Mailing Address - City:GUNTERSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35976-7277
Mailing Address - Country:US
Mailing Address - Phone:256-582-6439
Mailing Address - Fax:
Practice Address - Street 1:3656 AL HIGHWAY 69
Practice Address - Street 2:
Practice Address - City:GUNTERSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35976-7196
Practice Address - Country:US
Practice Address - Phone:256-571-7115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL11020183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL11020OtherPHARMACIST LISCENSE NUMBE