Provider Demographics
NPI:1184986473
Name:WILSON, CHARLES KEITH (R PH)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:KEITH
Last Name:WILSON
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-1839
Mailing Address - Country:US
Mailing Address - Phone:618-998-1269
Mailing Address - Fax:618-988-1323
Practice Address - Street 1:905 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-1839
Practice Address - Country:US
Practice Address - Phone:618-998-1269
Practice Address - Fax:618-988-1323
Is Sole Proprietor?:No
Enumeration Date:2012-06-12
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051035300183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist