Provider Demographics
NPI:1750509105
Name:WILSON, JAMES D (RPH)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:D
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 1:7726 KRUGE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46809-9713
Mailing Address - Country:US
Mailing Address - Phone:260-747-9187
Mailing Address - Fax:260-747-4137
Practice Address - Street 1:7726 KRUGE DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46809-9713
Practice Address - Country:US
Practice Address - Phone:260-747-9187
Practice Address - Fax:260-747-4137
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26013207A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist