Provider Demographics
NPI:1356457691
Name:WILSON, VANESSA KIM (RPH)
Entity Type:Individual
Prefix:MRS
First Name:VANESSA
Middle Name:KIM
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 1:10554 PRESTBURY DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46236-8200
Mailing Address - Country:US
Mailing Address - Phone:317-823-6199
Mailing Address - Fax:
Practice Address - Street 1:1700 E 38TH ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953-4568
Practice Address - Country:US
Practice Address - Phone:765-674-3321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-3-19838183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist