Provider Demographics
NPI:1396878526
Name:WILSON-SOUTHERLAND, MYRA JOY (RPH)
Entity type:Individual
Prefix:
First Name:MYRA
Middle Name:JOY
Last Name:WILSON-SOUTHERLAND
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:MRS
Other - First Name:JOY
Other - Middle Name:WILSON
Other - Last Name:SOUTHERLAND
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPH
Mailing Address - Street 1:1100 E WENDOVER AVE
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-6713
Mailing Address - Country:US
Mailing Address - Phone:336-641-6582
Mailing Address - Fax:336-641-6971
Practice Address - Street 1:1100 E WENDOVER AVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-6713
Practice Address - Country:US
Practice Address - Phone:336-641-6582
Practice Address - Fax:336-641-6971
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC05778183500000X, 1835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy