Provider Demographics
NPI:1154481869
Name:WILBORN, WILLIAM RICHARD (RPH)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:RICHARD
Last Name:WILBORN
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:PO BOX 37
Mailing Address - Street 2:
Mailing Address - City:ROSICLARE
Mailing Address - State:IL
Mailing Address - Zip Code:62982-0037
Mailing Address - Country:US
Mailing Address - Phone:618-285-6618
Mailing Address - Fax:618-285-3147
Practice Address - Street 1:# 7 FERRELL RD
Practice Address - Street 2:BOX 37
Practice Address - City:ROSICLARE
Practice Address - State:IL
Practice Address - Zip Code:62982-0037
Practice Address - Country:US
Practice Address - Phone:618-285-6618
Practice Address - Fax:618-285-3147
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist