Provider Demographics
NPI:1467776377
Name:WILSON, MICHAEL PAUL (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PAUL
Last Name:WILSON
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4520 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:WAKE VILLAGE
Mailing Address - State:TX
Mailing Address - Zip Code:75501-6354
Mailing Address - Country:US
Mailing Address - Phone:903-838-7539
Mailing Address - Fax:903-832-9055
Practice Address - Street 1:4520 W 7TH ST
Practice Address - Street 2:
Practice Address - City:WAKE VILLAGE
Practice Address - State:TX
Practice Address - Zip Code:75501-6354
Practice Address - Country:US
Practice Address - Phone:903-838-7539
Practice Address - Fax:903-832-9055
Is Sole Proprietor?:No
Enumeration Date:2010-03-22
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37177183500000X
LA16146183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX37177OtherSTATE OF TEXAS BOARD OF PHARMACY