Provider Demographics
NPI:1750667671
Name:WILFONG, JACK EDWARD
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:EDWARD
Last Name:WILFONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9600 N KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-4006
Mailing Address - Country:US
Mailing Address - Phone:843-449-2158
Mailing Address - Fax:843-692-7221
Practice Address - Street 1:9600 N KINGS HWY
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4006
Practice Address - Country:US
Practice Address - Phone:843-449-2158
Practice Address - Fax:843-692-7221
Is Sole Proprietor?:No
Enumeration Date:2011-10-24
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6772183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist