Provider Demographics
NPI:1720365505
Name:WILSON, AMANDA (PHARMD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 CORMIER RD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-4404
Mailing Address - Country:US
Mailing Address - Phone:920-499-2608
Mailing Address - Fax:920-593-9512
Practice Address - Street 1:1001 CORMIER RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-4404
Practice Address - Country:US
Practice Address - Phone:920-499-2608
Practice Address - Fax:920-593-9512
Is Sole Proprietor?:No
Enumeration Date:2011-11-08
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16329-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist