Provider Demographics
NPI:1669698148
Name:WILSON, WAYNE THOMAS (RPH)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:THOMAS
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 1:1955 JUNIPER ST
Mailing Address - Street 2:
Mailing Address - City:MCKINLEYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95519-8207
Mailing Address - Country:US
Mailing Address - Phone:707-839-0572
Mailing Address - Fax:
Practice Address - Street 1:2850 F ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-4423
Practice Address - Country:US
Practice Address - Phone:707-442-5774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38616183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist