Provider Demographics
NPI:1518569227
Name:WILSON, DEANNA
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 CHEYENNE CIR
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-7031
Mailing Address - Country:US
Mailing Address - Phone:219-916-1448
Mailing Address - Fax:
Practice Address - Street 1:308 N MAIN ST
Practice Address - Street 2:
Practice Address - City:HEBRON
Practice Address - State:IN
Practice Address - Zip Code:46341-8790
Practice Address - Country:US
Practice Address - Phone:219-996-2930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26019914A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist