Provider Demographics
NPI:1134640741
Name:WILSON, DEREK JAMES (RPH)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:JAMES
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 1:60 WAUGH CT
Mailing Address - Street 2:
Mailing Address - City:BRIDGEWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:08807-2598
Mailing Address - Country:US
Mailing Address - Phone:732-977-2061
Mailing Address - Fax:
Practice Address - Street 1:2A WALTER E FORAN BLVD
Practice Address - Street 2:
Practice Address - City:FLEMINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08822
Practice Address - Country:US
Practice Address - Phone:
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-05
Last Update Date:2017-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03860000183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist