Provider Demographics
NPI:1720353766
Name:WILSON, JAMES A (RPH)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:A
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 1:3 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:COQUILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97423-1846
Mailing Address - Country:US
Mailing Address - Phone:541-369-2422
Mailing Address - Fax:541-396-6613
Practice Address - Street 1:1020 S FIRST AVE
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-0000
Practice Address - Country:US
Practice Address - Phone:541-269-4033
Practice Address - Fax:541-269-4034
Is Sole Proprietor?:No
Enumeration Date:2012-03-08
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR007070183500000X
OR70701835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist