Provider Demographics
NPI:1396025052
Name:WILSON, NICHOLE RAE (PHARMD)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:RAE
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 MOUNTAIN LAUREL PL
Mailing Address - Street 2:
Mailing Address - City:ANGIER
Mailing Address - State:NC
Mailing Address - Zip Code:27501-6850
Mailing Address - Country:US
Mailing Address - Phone:919-906-7099
Mailing Address - Fax:
Practice Address - Street 1:10050 GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27617-8436
Practice Address - Country:US
Practice Address - Phone:919-596-6821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-25
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21868183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist