Provider Demographics
NPI:1114299435
Name:WILSON, EARNEST HAYNE JR (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:EARNEST
Middle Name:HAYNE
Last Name:WILSON
Suffix:JR
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2730 YORKSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-3731
Mailing Address - Country:US
Mailing Address - Phone:321-607-9856
Mailing Address - Fax:321-269-9510
Practice Address - Street 1:2605 BARNA AVE
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-5452
Practice Address - Country:US
Practice Address - Phone:321-269-7392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-01
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS23356183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist