Provider Demographics
NPI:1225715766
Name:WILSON, ROBERTA
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 W WACKERLY ST STE 1600
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-4710
Mailing Address - Country:US
Mailing Address - Phone:989-794-0265
Mailing Address - Fax:
Practice Address - Street 1:555 W WACKERLY ST STE 1600
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-4710
Practice Address - Country:US
Practice Address - Phone:989-794-0265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-28
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53024127451835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care