Provider Demographics
NPI:1881964724
Name:WILSON, JAMES LOFTIN JR (RPH)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:LOFTIN
Last Name:WILSON
Suffix:JR
Gender:M
Credentials:RPH
Other - Prefix:MR
Other - First Name:JAMES
Other - Middle Name:LOFTIN
Other - Last Name:WILSON
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:1381 PIO NONO AVE
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-4633
Mailing Address - Country:US
Mailing Address - Phone:478-742-1486
Mailing Address - Fax:
Practice Address - Street 1:1381 PIO NONO AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-4633
Practice Address - Country:US
Practice Address - Phone:478-742-1486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-10
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10787183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist