Provider Demographics
NPI:1346513439
Name:WILSON, SUSAN P (RPH)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:P
Last Name:WILSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2811 W 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-3104
Mailing Address - Country:US
Mailing Address - Phone:509-735-8733
Mailing Address - Fax:509-735-8727
Practice Address - Street 1:2811 W 10TH AVE
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-3104
Practice Address - Country:US
Practice Address - Phone:509-735-8733
Practice Address - Fax:509-735-8727
Is Sole Proprietor?:No
Enumeration Date:2012-02-20
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00053582183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist