Provider Demographics
NPI:1922321959
Name:WILSON, MICHELLE PAULINE (PHARM D)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:PAULINE
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6849 IVES RD
Mailing Address - Street 2:
Mailing Address - City:MARCY
Mailing Address - State:NY
Mailing Address - Zip Code:13403-2930
Mailing Address - Country:US
Mailing Address - Phone:518-651-4323
Mailing Address - Fax:
Practice Address - Street 1:2024 GENESEE ST
Practice Address - Street 2:WALMART PHARMACY
Practice Address - City:ONEIDA
Practice Address - State:NY
Practice Address - Zip Code:13421
Practice Address - Country:US
Practice Address - Phone:315-361-1184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-04
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053894183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist