Provider Demographics
NPI:1861487340
Name:WILSON, JUSTIN BLAKE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:BLAKE
Last Name:WILSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3025 ELIE ST
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-1964
Mailing Address - Country:US
Mailing Address - Phone:405-701-5970
Mailing Address - Fax:405-741-1224
Practice Address - Street 1:1212A S DOUGLAS BLVD
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73130-5213
Practice Address - Country:US
Practice Address - Phone:405-741-1200
Practice Address - Fax:405-741-1224
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13059183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist