Provider Demographics
NPI:1245381748
Name:WILSON, LYDIA A (RPH)
Entity Type:Individual
Prefix:MRS
First Name:LYDIA
Middle Name:A
Last Name:WILSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 VALLEY TERRACE RD
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-4974
Mailing Address - Country:US
Mailing Address - Phone:817-447-0218
Mailing Address - Fax:
Practice Address - Street 1:124 W RENFRO ST
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-4260
Practice Address - Country:US
Practice Address - Phone:817-295-6128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29117183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX29117OtherLICENSE