Provider Demographics
NPI:1114158805
Name:WILSON, RODGER PAUL (RPH)
Entity Type:Individual
Prefix:MR
First Name:RODGER
Middle Name:PAUL
Last Name:WILSON
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 1:1138 WYNDEMERE CIR
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-2322
Mailing Address - Country:US
Mailing Address - Phone:303-579-1100
Mailing Address - Fax:303-702-9133
Practice Address - Street 1:1138 WYNDEMERE CIR
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-2322
Practice Address - Country:US
Practice Address - Phone:303-579-1100
Practice Address - Fax:303-702-9133
Is Sole Proprietor?:No
Enumeration Date:2009-07-29
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1996183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist