Provider Demographics
NPI:1417293523
Name:WILSON, ELLEN JETT (RPH, PHD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:JETT
Last Name:WILSON
Suffix:
Gender:F
Credentials:RPH, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 PARKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-5241
Mailing Address - Country:US
Mailing Address - Phone:864-230-8819
Mailing Address - Fax:
Practice Address - Street 1:655 FAIRVIEW RD
Practice Address - Street 2:SUITE C
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29680-7500
Practice Address - Country:US
Practice Address - Phone:864-962-0251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-17
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7876183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist