Provider Demographics
NPI:1558034462
Name:WILSON, JEFFREY ALLEN (PHARMD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ALLEN
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 1:1029 PALO DURO TRL
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-4984
Mailing Address - Country:US
Mailing Address - Phone:817-789-3020
Mailing Address - Fax:
Practice Address - Street 1:6984 RUFE SNOW DR
Practice Address - Street 2:
Practice Address - City:NORTH RICHLAND HILLS
Practice Address - State:TX
Practice Address - Zip Code:76148-2356
Practice Address - Country:US
Practice Address - Phone:817-427-9353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-27
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX68748183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist