Provider Demographics
NPI:1992180749
Name:WILSON, KASEY (PHARMD)
Entity Type:Individual
Prefix:
First Name:KASEY
Middle Name:
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 1:503 PEDEN RD
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN INN
Mailing Address - State:SC
Mailing Address - Zip Code:29644-9123
Mailing Address - Country:US
Mailing Address - Phone:864-915-8733
Mailing Address - Fax:
Practice Address - Street 1:207 W BUTLER RD
Practice Address - Street 2:
Practice Address - City:MAULDIN
Practice Address - State:SC
Practice Address - Zip Code:29662-2536
Practice Address - Country:US
Practice Address - Phone:864-458-8907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-22
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC36230183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist