Provider Demographics
NPI:1598039851
Name:WILSON, BRYANT JAMES (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:BRYANT
Middle Name:JAMES
Last Name:WILSON
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1244 HANLIN WAY
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-4335
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:651 COLLIERS WAY
Practice Address - Street 2:SUITE 204
Practice Address - City:WEIRTON
Practice Address - State:WV
Practice Address - Zip Code:26062-5053
Practice Address - Country:US
Practice Address - Phone:304-723-6331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-05
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0007448183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVRP0007448OtherPHARMACY LICENSE