Provider Demographics
NPI:1164060745
Name:WILSON, COZI (PHARMD)
Entity Type:Individual
Prefix:
First Name:COZI
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:COMANCHE
Mailing Address - State:TX
Mailing Address - Zip Code:76442-2706
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:404 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:COMANCHE
Practice Address - State:TX
Practice Address - Zip Code:76442-2706
Practice Address - Country:US
Practice Address - Phone:325-356-5276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-14
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX39257183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX81189Medicaid