Provider Demographics
NPI:1760598940
Name:WILSON, LAWRENCE WADE (RPH)
Entity Type:Individual
Prefix:MR
First Name:LAWRENCE
Middle Name:WADE
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 1:504 HEARTHSTONE CIR
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4323
Mailing Address - Country:US
Mailing Address - Phone:615-371-8225
Mailing Address - Fax:
Practice Address - Street 1:275 CUMBERLAND BND
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37228-1805
Practice Address - Country:US
Practice Address - Phone:615-743-1609
Practice Address - Fax:615-743-1670
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNC-5331183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist