Provider Demographics
NPI:1801472626
Name:WILSON PHARMACY GROUP, LLC
Entity type:Organization
Organization Name:WILSON PHARMACY GROUP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:806-652-3353
Mailing Address - Street 1:PO BOX 685
Mailing Address - Street 2:
Mailing Address - City:LOCKNEY
Mailing Address - State:TX
Mailing Address - Zip Code:79241-0685
Mailing Address - Country:US
Mailing Address - Phone:806-652-3353
Mailing Address - Fax:806-652-2118
Practice Address - Street 1:1224 MAIN STREET
Practice Address - Street 2:
Practice Address - City:MATADOR
Practice Address - State:TX
Practice Address - Zip Code:79244
Practice Address - Country:US
Practice Address - Phone:806-652-3353
Practice Address - Fax:806-652-2118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-22
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX150426Medicaid