Provider Demographics
NPI:1609158393
Name:WILSON, POLLY ELIZABETH (PHARMD)
Entity Type:Individual
Prefix:
First Name:POLLY
Middle Name:ELIZABETH
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:POLLY
Other - Middle Name:ELIZABETH
Other - Last Name:FUNK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:7626 PRINCE DR
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-7148
Mailing Address - Country:US
Mailing Address - Phone:423-910-0259
Mailing Address - Fax:
Practice Address - Street 1:2399 MCGRADY DR SE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37323-7147
Practice Address - Country:US
Practice Address - Phone:423-559-9094
Practice Address - Fax:423-559-9116
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-19
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN27713183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist