Provider Demographics
NPI:1508148644
Name:WILSON, BRIAN SCOTT (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:SCOTT
Last Name:WILSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 N SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:OGALLALA
Mailing Address - State:NE
Mailing Address - Zip Code:69153-2548
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23 N SPRUCE ST
Practice Address - Street 2:
Practice Address - City:OGALLALA
Practice Address - State:NE
Practice Address - Zip Code:69153-2548
Practice Address - Country:US
Practice Address - Phone:308-284-2242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-14
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO17071183500000X
NE14118183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist