Provider Demographics
NPI:1659962413
Name:WILSON, CORRIE
Entity Type:Individual
Prefix:
First Name:CORRIE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 POINTER LN
Mailing Address - Street 2:
Mailing Address - City:ZION CROSSROADS
Mailing Address - State:VA
Mailing Address - Zip Code:22942-6864
Mailing Address - Country:US
Mailing Address - Phone:757-876-0822
Mailing Address - Fax:
Practice Address - Street 1:545 RAFORD LANE
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903
Practice Address - Country:US
Practice Address - Phone:434-823-4151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-03
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202217018183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist