Provider Demographics
NPI:1790830396
Name:WILSON, PAMELA R
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:R
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1630 HIGHWAY 183
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:KS
Mailing Address - Zip Code:67669-8863
Mailing Address - Country:US
Mailing Address - Phone:785-425-7257
Mailing Address - Fax:
Practice Address - Street 1:402 MAIN ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:KS
Practice Address - Zip Code:67669-1930
Practice Address - Country:US
Practice Address - Phone:785-425-7172
Practice Address - Fax:755-425-6611
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-00126183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS14-00126OtherPHARM. TECH STATE LICENSE