Provider Demographics
NPI:1669740676
Name:WILBANKS, WILMA JOHNSON (RPH)
Entity type:Individual
Prefix:MRS
First Name:WILMA
Middle Name:JOHNSON
Last Name:WILBANKS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:537 ROBINSON DR
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-2213
Mailing Address - Country:US
Mailing Address - Phone:662-843-6520
Mailing Address - Fax:662-846-7657
Practice Address - Street 1:301 N DAVIS AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-2349
Practice Address - Country:US
Practice Address - Phone:662-846-5781
Practice Address - Fax:662-846-7657
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-05
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-06978183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist