Provider Demographics
NPI:1558969188
Name:WILSON, CHRISTIANE
Entity Type:Individual
Prefix:
First Name:CHRISTIANE
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 1:4232 LANSMOORE XING
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-6969
Mailing Address - Country:US
Mailing Address - Phone:404-542-7141
Mailing Address - Fax:
Practice Address - Street 1:7380 SPOUT SPRINGS RD
Practice Address - Street 2:
Practice Address - City:FLOWERY BRANCH
Practice Address - State:GA
Practice Address - Zip Code:30542-7541
Practice Address - Country:US
Practice Address - Phone:770-965-5644
Practice Address - Fax:770-965-5632
Is Sole Proprietor?:No
Enumeration Date:2020-10-15
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA021678183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist