Provider Demographics
NPI:1154678597
Name:WILLIAMSON, JED (PHARMD)
Entity Type:Individual
Prefix:
First Name:JED
Middle Name:
Last Name:WILLIAMSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 W MCCOY BLVD
Mailing Address - Street 2:
Mailing Address - City:TOMAH
Mailing Address - State:WI
Mailing Address - Zip Code:54660-3291
Mailing Address - Country:US
Mailing Address - Phone:608-372-7557
Mailing Address - Fax:608-372-7765
Practice Address - Street 1:222 W MCCOY BLVD
Practice Address - Street 2:
Practice Address - City:TOMAH
Practice Address - State:WI
Practice Address - Zip Code:54660-3291
Practice Address - Country:US
Practice Address - Phone:608-372-7557
Practice Address - Fax:608-372-7765
Is Sole Proprietor?:No
Enumeration Date:2012-08-03
Last Update Date:2013-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17235-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist