Provider Demographics
NPI:1639471147
Name:WILEY, WILLIAM GLEN (RPH)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:GLEN
Last Name:WILEY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1190 LICKINGHOLE RD
Mailing Address - Street 2:
Mailing Address - City:GOOCHLAND
Mailing Address - State:VA
Mailing Address - Zip Code:23063-3821
Mailing Address - Country:US
Mailing Address - Phone:804-385-3963
Mailing Address - Fax:
Practice Address - Street 1:1904 EMMET ST N
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22901-2815
Practice Address - Country:US
Practice Address - Phone:434-295-2132
Practice Address - Fax:434-295-0677
Is Sole Proprietor?:No
Enumeration Date:2010-12-03
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02022048951835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy