Provider Demographics
NPI:1700481249
Name:WILSON, PENNY LAINE
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:LAINE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PENNY
Other - Middle Name:LAINE
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARM D
Mailing Address - Street 1:1606 PARK RIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:CAVE SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72718-8443
Mailing Address - Country:US
Mailing Address - Phone:479-381-5351
Mailing Address - Fax:
Practice Address - Street 1:2252 N 8TH ST
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-2842
Practice Address - Country:US
Practice Address - Phone:479-621-9188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018037540183500000X
ARPD10308183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist