Provider Demographics
NPI:1558608422
Name:WILSON, KEVIN LANE (RPH)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:LANE
Last Name:WILSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14444 BEACH BLVD STE 6
Mailing Address - Street 2:PUBLIX PHARMACY #433
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32250-2010
Mailing Address - Country:US
Mailing Address - Phone:904-223-0423
Mailing Address - Fax:904-223-3316
Practice Address - Street 1:14444 BEACH BLVD STE 6
Practice Address - Street 2:PUBLIX PHARMACY #433
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32250-2010
Practice Address - Country:US
Practice Address - Phone:904-223-0423
Practice Address - Fax:904-223-3316
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-11
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS0017762183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist