Provider Demographics
NPI:1346324464
Name:JAMES A WILSON
Entity Type:Organization
Organization Name:JAMES A WILSON
Other - Org Name:SIX TWELVE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHRM
Authorized Official - Phone:626-447-4572
Mailing Address - Street 1:107 W HUNTINGTON DR
Mailing Address - Street 2:STE A
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91007-3026
Mailing Address - Country:US
Mailing Address - Phone:626-446-4400
Mailing Address - Fax:626-446-2320
Practice Address - Street 1:107 W HUNTINGTON DR
Practice Address - Street 2:STE A
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91007-3026
Practice Address - Country:US
Practice Address - Phone:626-446-4400
Practice Address - Fax:626-447-2320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY362223336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2028484OtherPK