Provider Demographics
NPI:1396407557
Name:WILLIS, VICTORIA PAIGE
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:PAIGE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 399
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-0399
Mailing Address - Country:US
Mailing Address - Phone:706-333-5074
Mailing Address - Fax:
Practice Address - Street 1:1425 S HWY 89
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8515
Practice Address - Country:US
Practice Address - Phone:307-733-8746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-05
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY4316183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist