Provider Demographics
NPI:1598799249
Name:WILSON, CHARLES PHILLIPS (PD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:PHILLIPS
Last Name:WILSON
Suffix:
Gender:M
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10130 HONEYSUCKLE RD
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72824-8940
Mailing Address - Country:US
Mailing Address - Phone:479-495-0276
Mailing Address - Fax:
Practice Address - Street 1:10130 HONEYSUCKLE RD
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72824-8940
Practice Address - Country:US
Practice Address - Phone:479-495-0276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR6294183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist