Provider Demographics
NPI:1326387309
Name:TAM, WILSON (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:WILSON
Middle Name:
Last Name:TAM
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6702 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204-4452
Mailing Address - Country:US
Mailing Address - Phone:347-513-2858
Mailing Address - Fax:
Practice Address - Street 1:532 BROADHOLLOW RD STE 137
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-3609
Practice Address - Country:US
Practice Address - Phone:347-513-2858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-11
Last Update Date:2013-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0565491835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist