Provider Demographics
NPI:1336453547
Name:WILSON, JENNIFER ASHLEY (PHARMD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ASHLEY
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ASHLEY
Other - Last Name:WAITZMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:515 N. MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:WINGATE
Mailing Address - State:NC
Mailing Address - Zip Code:28174-5729
Mailing Address - Country:US
Mailing Address - Phone:704-233-8964
Mailing Address - Fax:702-233-8332
Practice Address - Street 1:515 N. MAIN ST.
Practice Address - Street 2:
Practice Address - City:WINGATE
Practice Address - State:NC
Practice Address - Zip Code:28174
Practice Address - Country:US
Practice Address - Phone:704-233-8964
Practice Address - Fax:704-233-8332
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-29
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21391183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist