Provider Demographics
NPI:1346564788
Name:WILSON, SEAN MILLER
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:MILLER
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8441 RIDGEWAY AVE
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99504-4188
Mailing Address - Country:US
Mailing Address - Phone:727-709-0277
Mailing Address - Fax:
Practice Address - Street 1:5955 ZEAMER AVE
Practice Address - Street 2:
Practice Address - City:JBER
Practice Address - State:AK
Practice Address - Zip Code:99506-3702
Practice Address - Country:US
Practice Address - Phone:727-709-0277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-14
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLPS473181835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program