Provider Demographics
NPI:1427200872
Name:WILSON PHARMACY, INC.
Entity Type:Organization
Organization Name:WILSON PHARMACY, INC.
Other - Org Name:WILSON PHARMACY WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:KILGORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-915-5185
Mailing Address - Street 1:311 PRINCETON RD STE 1
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-2026
Mailing Address - Country:US
Mailing Address - Phone:423-926-6154
Mailing Address - Fax:426-926-7965
Practice Address - Street 1:525 N STATE OF FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-8213
Practice Address - Country:US
Practice Address - Phone:423-926-6154
Practice Address - Fax:423-926-7965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-16
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4903336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3912397Medicare PIN