Provider Demographics
NPI:1932483633
Name:WILSON, STEVEN R (RPH)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:R
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 1:1402 OHIO AVE
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444-3743
Mailing Address - Country:US
Mailing Address - Phone:850-265-0499
Mailing Address - Fax:850-265-6563
Practice Address - Street 1:1402 OHIO AVE
Practice Address - Street 2:
Practice Address - City:LYNN HAVEN
Practice Address - State:FL
Practice Address - Zip Code:32444-3743
Practice Address - Country:US
Practice Address - Phone:850-265-0499
Practice Address - Fax:850-265-6563
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-30
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS17045183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist