Provider Demographics
NPI:1457336521
Name:WILSON, BEVERLY DEANN (PHARM D)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:DEANN
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5107 DEER CREEK CT
Mailing Address - Street 2:
Mailing Address - City:FLOWERY BRANCH
Mailing Address - State:GA
Mailing Address - Zip Code:30542-3569
Mailing Address - Country:US
Mailing Address - Phone:770-773-6957
Mailing Address - Fax:
Practice Address - Street 1:199 E LOUISE ST
Practice Address - Street 2:
Practice Address - City:CLARKESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30523-6019
Practice Address - Country:US
Practice Address - Phone:706-754-3933
Practice Address - Fax:706-754-3974
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-13
Last Update Date:2017-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA15041183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist