Provider Demographics
NPI:1013235589
Name:WILLSON, SAMUEL A (RPH)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:A
Last Name:WILLSON
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 1:111 LOUISE LN
Mailing Address - Street 2:
Mailing Address - City:BURNET
Mailing Address - State:TX
Mailing Address - Zip Code:78611-3556
Mailing Address - Country:US
Mailing Address - Phone:512-715-0828
Mailing Address - Fax:830-693-2123
Practice Address - Street 1:1503 HIGHWAY 1431
Practice Address - Street 2:
Practice Address - City:MARBLE FALLS
Practice Address - State:TX
Practice Address - Zip Code:78654-4902
Practice Address - Country:US
Practice Address - Phone:830-693-4810
Practice Address - Fax:830-693-2123
Is Sole Proprietor?:No
Enumeration Date:2010-05-09
Last Update Date:2010-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28237183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist