Provider Demographics
NPI:1902044217
Name:WILSON, NICOLE ANN (PHARMD)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:ANN
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 RAILROAD STREET
Mailing Address - Street 2:
Mailing Address - City:ST. MARYS
Mailing Address - State:PA
Mailing Address - Zip Code:15857-1798
Mailing Address - Country:US
Mailing Address - Phone:814-834-3017
Mailing Address - Fax:814-834-1031
Practice Address - Street 1:4 RAILROAD STREET
Practice Address - Street 2:
Practice Address - City:ST. MARYS
Practice Address - State:PA
Practice Address - Zip Code:15857-1798
Practice Address - Country:US
Practice Address - Phone:814-834-3017
Practice Address - Fax:814-834-1031
Is Sole Proprietor?:No
Enumeration Date:2009-01-23
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP442898183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist