Provider Demographics
NPI:1154825669
Name:WILSON, AMBRA LYNN (PHARM D)
Entity Type:Individual
Prefix:
First Name:AMBRA
Middle Name:LYNN
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 WALTON DR
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:TN
Mailing Address - Zip Code:37185-3382
Mailing Address - Country:US
Mailing Address - Phone:931-296-9984
Mailing Address - Fax:931-296-1935
Practice Address - Street 1:275 WALTON DR
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:TN
Practice Address - Zip Code:37185-3382
Practice Address - Country:US
Practice Address - Phone:931-296-9984
Practice Address - Fax:931-296-1935
Is Sole Proprietor?:No
Enumeration Date:2018-03-20
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN23927183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist