Provider Demographics
NPI:1598387458
Name:WILSON, KENNETH (PHARMD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
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 1:3001 CALLA LILLY
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-6714
Mailing Address - Country:US
Mailing Address - Phone:801-879-9920
Mailing Address - Fax:
Practice Address - Street 1:HWY 491 NORTH
Practice Address - Street 2:
Practice Address - City:SHIPROCK
Practice Address - State:NM
Practice Address - Zip Code:87420
Practice Address - Country:US
Practice Address - Phone:505-368-6001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-14
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5881924-1707183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist