Provider Demographics
NPI:1447790712
Name:WILSON, WALTER (RPH PHD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
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 1:706 MARC TAYLOR DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-3706
Mailing Address - Country:US
Mailing Address - Phone:512-443-8984
Mailing Address - Fax:512-443-9220
Practice Address - Street 1:1340 AIRPORT COMMERCE DR
Practice Address - Street 2:BLD 3 STE 350
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78741-6831
Practice Address - Country:US
Practice Address - Phone:512-443-8984
Practice Address - Fax:512-443-9220
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-06
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36945183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist