Provider Demographics
NPI:1275540304
Name:JO NELL WILKINSON & WILLIAM JACK WILKINSON
Entity Type:Organization
Organization Name:JO NELL WILKINSON & WILLIAM JACK WILKINSON
Other - Org Name:KERMIT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:JO NELL
Authorized Official - Middle Name:
Authorized Official - Last Name:WILKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:325-396-4630
Mailing Address - Street 1:PO BOX 947
Mailing Address - Street 2:
Mailing Address - City:MENARD
Mailing Address - State:TX
Mailing Address - Zip Code:76859-0947
Mailing Address - Country:US
Mailing Address - Phone:325-396-4630
Mailing Address - Fax:
Practice Address - Street 1:810 MYER LN
Practice Address - Street 2:
Practice Address - City:KERMIT
Practice Address - State:TX
Practice Address - Zip Code:79745-4634
Practice Address - Country:US
Practice Address - Phone:432-586-2556
Practice Address - Fax:432-586-5934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15496332B00000X, 332BX2000X, 3336L0003X
TX255983336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0913493-01Medicaid
TX0140386-01Medicaid
NM00057606Medicaid
TX143959OtherTEXAS MEDICAID VENDOR DRUG
NM000T4272Medicaid
NM00057606Medicaid