Provider Demographics
NPI:1871835843
Name:WILSON, JON JOSEPH (RPH)
Entity Type:Individual
Prefix:MR
First Name:JON
Middle Name:JOSEPH
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 1:117 W WEBSTER ST
Mailing Address - Street 2:
Mailing Address - City:CUBA CITY
Mailing Address - State:WI
Mailing Address - Zip Code:53807-1100
Mailing Address - Country:US
Mailing Address - Phone:608-744-2195
Mailing Address - Fax:608-744-2193
Practice Address - Street 1:117 W WEBSTER ST
Practice Address - Street 2:
Practice Address - City:CUBA CITY
Practice Address - State:WI
Practice Address - Zip Code:53807-1100
Practice Address - Country:US
Practice Address - Phone:608-744-2195
Practice Address - Fax:608-744-2193
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-18
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11608-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist