Provider Demographics
NPI:1205135282
Name:WILSON, MELBA E (RPH)
Entity type:Individual
Prefix:
First Name:MELBA
Middle Name:E
Last Name:WILSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:757 FAIRVIEW RD
Mailing Address - Street 2:
Mailing Address - City:HARRIMAN
Mailing Address - State:TN
Mailing Address - Zip Code:37748-3622
Mailing Address - Country:US
Mailing Address - Phone:865-435-2361
Mailing Address - Fax:
Practice Address - Street 1:490 E TRI COUNTY BLVD
Practice Address - Street 2:
Practice Address - City:OLIVER SPRINGS
Practice Address - State:TN
Practice Address - Zip Code:37840-2001
Practice Address - Country:US
Practice Address - Phone:865-435-7724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-16
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1531183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist