Provider Demographics
NPI:1730143793
Name:WILSON, MICHAEL SCOT (RPH)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SCOT
Last Name:WILSON
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 1:4411 GA HIGHWAY 107
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:GA
Mailing Address - Zip Code:31714-3602
Mailing Address - Country:US
Mailing Address - Phone:229-567-4979
Mailing Address - Fax:
Practice Address - Street 1:1444 TIFT AVE N
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-4618
Practice Address - Country:US
Practice Address - Phone:229-391-9490
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA016589183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist