Provider Demographics
NPI:1164550604
Name:WILSON, ELIZABETH DARLENE (RPH, CH)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:DARLENE
Last Name:WILSON
Suffix:
Gender:F
Credentials:RPH, CH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19433 SE 266TH ST
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98042-5037
Mailing Address - Country:US
Mailing Address - Phone:253-631-1294
Mailing Address - Fax:253-630-1902
Practice Address - Street 1:19433 SE 266TH ST
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:WA
Practice Address - Zip Code:98042-5037
Practice Address - Country:US
Practice Address - Phone:253-631-1294
Practice Address - Fax:253-630-1902
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00009601183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist