Provider Demographics
NPI:1326649492
Name:STEWART-WILSON, SHIRLEY ANNETTE
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:ANNETTE
Last Name:STEWART-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 1:6954 SHOREVIEW DR
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75054-6847
Mailing Address - Country:US
Mailing Address - Phone:214-674-6244
Mailing Address - Fax:
Practice Address - Street 1:400 N HIGHWAY 67
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:TX
Practice Address - Zip Code:76065-8000
Practice Address - Country:US
Practice Address - Phone:972-775-4708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36425183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist