Provider Demographics
NPI:1780288399
Name:WILSON, LESLIE
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6250 HIGHWAY 83/84
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79606
Mailing Address - Country:US
Mailing Address - Phone:325-428-1600
Mailing Address - Fax:325-428-1619
Practice Address - Street 1:6250 HIGHWAY 83/84
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79606
Practice Address - Country:US
Practice Address - Phone:325-428-1600
Practice Address - Fax:325-428-1619
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-24
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30749183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist