Provider Demographics
NPI:1467557959
Name:WILSON, REBECCA MARIA (CPHT)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:MARIA
Last Name:WILSON
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1095 ARAGO AVE
Mailing Address - Street 2:PO BOX 3562
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2807
Mailing Address - Country:US
Mailing Address - Phone:541-888-4911
Mailing Address - Fax:
Practice Address - Street 1:1775 THOMPSON RD
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2125
Practice Address - Country:US
Practice Address - Phone:541-269-8160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORCPT510183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician