Provider Demographics
NPI:1801103742
Name:WILSON, SUSAN IRENE (RPH)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:IRENE
Last Name:WILSON
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 1:950 FAIR ST
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-1806
Mailing Address - Country:US
Mailing Address - Phone:928-778-6887
Mailing Address - Fax:928-776-9874
Practice Address - Street 1:950 FAIR ST
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-1806
Practice Address - Country:US
Practice Address - Phone:928-778-6887
Practice Address - Fax:928-776-9874
Is Sole Proprietor?:No
Enumeration Date:2010-09-13
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS014295183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ03656900Medicare Oscar/Certification