Provider Demographics
NPI:1598234775
Name:WILSON, DOUG (PHARM D)
Entity Type:Individual
Prefix:
First Name:DOUG
Middle Name:
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 1:981 44TH ST SE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52403-3923
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2900 HEARTLAND DR
Practice Address - Street 2:
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241-2740
Practice Address - Country:US
Practice Address - Phone:319-545-3201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-18
Last Update Date:2018-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14755183500000X
IA20533183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI14755OtherPHARMACY LICENSE NUMBER
IA20533OtherPHARMACY LICENSE NUMBER