Provider Demographics
NPI:1467742684
Name:WILSON, CYNTHIA JANE (RPH)
Entity Type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:JANE
Last Name:WILSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3124 LONG BEACH RD
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-3299
Mailing Address - Country:US
Mailing Address - Phone:516-764-9600
Mailing Address - Fax:516-764-0218
Practice Address - Street 1:3124 LONG BEACH RD
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:NY
Practice Address - Zip Code:11572-3299
Practice Address - Country:US
Practice Address - Phone:516-764-9600
Practice Address - Fax:516-764-0218
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-08
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040742183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist