Provider Demographics
NPI:1720008378
Name:WILSON, MILDRED THOMAS (RPH)
Entity Type:Individual
Prefix:MRS
First Name:MILDRED
Middle Name:THOMAS
Last Name:WILSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1260 NW 79TH AVE
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33322-4729
Mailing Address - Country:US
Mailing Address - Phone:954-452-2443
Mailing Address - Fax:954-321-2688
Practice Address - Street 1:499 NW 70TH AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33317-7500
Practice Address - Country:US
Practice Address - Phone:954-321-2682
Practice Address - Fax:954-321-2688
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13142183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist