Provider Demographics
NPI:1760474357
Name:WILSON, DWAYNE G (RP, CDM)
Entity Type:Individual
Prefix:
First Name:DWAYNE
Middle Name:G
Last Name:WILSON
Suffix:
Gender:M
Credentials:RP, CDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7524 KARL DR
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-4372
Mailing Address - Country:US
Mailing Address - Phone:402-489-2915
Mailing Address - Fax:402-489-3052
Practice Address - Street 1:7524 KARL DR
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-4372
Practice Address - Country:US
Practice Address - Phone:402-489-2915
Practice Address - Fax:402-489-3052
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE7975183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist