Provider Demographics
NPI:1730475484
Name:WILSON, CHARLES MARION (RPH)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:MARION
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 1:5712 CASTLE HAYNE RD
Mailing Address - Street 2:
Mailing Address - City:CASTLE HAYNE
Mailing Address - State:NC
Mailing Address - Zip Code:28429-5112
Mailing Address - Country:US
Mailing Address - Phone:910-675-2222
Mailing Address - Fax:910-675-2643
Practice Address - Street 1:5712 CASTLE HAYNE RD
Practice Address - Street 2:
Practice Address - City:CASTLE HAYNE
Practice Address - State:NC
Practice Address - Zip Code:28429-5112
Practice Address - Country:US
Practice Address - Phone:910-675-2222
Practice Address - Fax:910-675-2643
Is Sole Proprietor?:No
Enumeration Date:2011-06-21
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC06965183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0655597Medicaid