Provider Demographics
NPI:1205182110
Name:WILSON, BRYAN MARK (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:MARK
Last Name:WILSON
Suffix:
Gender:M
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 1:6358 HARBOUR STAR DR
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33467-6842
Mailing Address - Country:US
Mailing Address - Phone:561-309-2604
Mailing Address - Fax:
Practice Address - Street 1:501 SE 18TH AVENUE
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33435
Practice Address - Country:US
Practice Address - Phone:561-292-4085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-28
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS49231183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist