Provider Demographics
NPI:1326253766
Name:WILSON, WENSY S
Entity Type:Individual
Prefix:
First Name:WENSY
Middle Name:S
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 1:5430 WESTBROOK DRIVE
Mailing Address - Street 2:
Mailing Address - City:CLIO
Mailing Address - State:MI
Mailing Address - Zip Code:48420-8277
Mailing Address - Country:US
Mailing Address - Phone:810-686-1722
Mailing Address - Fax:
Practice Address - Street 1:1565 E PIERSON RD
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:MI
Practice Address - Zip Code:48433-1816
Practice Address - Country:US
Practice Address - Phone:810-659-2940
Practice Address - Fax:810-659-1799
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302029131183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2337752Medicare UPIN