Provider Demographics
NPI:1295289387
Name:WILSON, BRUCE ALAN (RPH)
Entity type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:ALAN
Last Name:WILSON
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 1:107 FRESH POND LN
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:NH
Mailing Address - Zip Code:03033-2114
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:125 DUBLIN RD
Practice Address - Street 2:
Practice Address - City:PETERBOROUGH
Practice Address - State:NH
Practice Address - Zip Code:03458-1343
Practice Address - Country:US
Practice Address - Phone:603-924-6397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-07
Last Update Date:2016-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHR1592183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist