Provider Demographics
NPI:1942784665
Name:WILSON, JONI M
Entity Type:Individual
Prefix:
First Name:JONI
Middle Name:M
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JONI
Other - Middle Name:M
Other - Last Name:FLOWERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1215 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75961-4034
Mailing Address - Country:US
Mailing Address - Phone:936-569-9884
Mailing Address - Fax:936-569-6848
Practice Address - Street 1:1215 NORTH ST
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961-4034
Practice Address - Country:US
Practice Address - Phone:936-569-9884
Practice Address - Fax:936-569-6848
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15890183500000X
TX39143183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist