Provider Demographics
NPI:1912511049
Name:LANG, WILSON DAVID
Entity Type:Individual
Prefix:
First Name:WILSON
Middle Name:DAVID
Last Name:LANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 TONINI DR APT 113
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-7447
Mailing Address - Country:US
Mailing Address - Phone:832-955-5004
Mailing Address - Fax:
Practice Address - Street 1:1720 TONINI DR APT 113
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-7447
Practice Address - Country:US
Practice Address - Phone:832-955-5004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-05
Last Update Date:2020-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA82406183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist