Provider Demographics
NPI:1508231002
Name:WILSON, JED (PHARMD)
Entity Type:Individual
Prefix:
First Name:JED
Middle Name:
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 1:85 CORWIN ST APT 3
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94114-2382
Mailing Address - Country:US
Mailing Address - Phone:816-719-7436
Mailing Address - Fax:
Practice Address - Street 1:399 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:SOUTH SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94080-5923
Practice Address - Country:US
Practice Address - Phone:650-583-8685
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-09
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA74215183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist