Provider Demographics
NPI:1689261067
Name:WILSON, MARK STEVEN (PHARM D)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:STEVEN
Last Name:WILSON
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1731 FOSTER CT
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-1740
Mailing Address - Country:US
Mailing Address - Phone:831-247-1648
Mailing Address - Fax:
Practice Address - Street 1:1226 SOQUEL AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-2157
Practice Address - Country:US
Practice Address - Phone:831-423-2315
Practice Address - Fax:831-423-2320
Is Sole Proprietor?:No
Enumeration Date:2020-12-31
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29684183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist