Provider Demographics
NPI:1952900714
Name:WILSON, MAURICE VONDELL (RPH)
Entity Type:Individual
Prefix:MR
First Name:MAURICE
Middle Name:VONDELL
Last Name:WILSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7746 BAY STREET
Mailing Address - Street 2:
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958
Mailing Address - Country:US
Mailing Address - Phone:772-589-2043
Mailing Address - Fax:772-388-2628
Practice Address - Street 1:7746 BAY STREET
Practice Address - Street 2:
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958
Practice Address - Country:US
Practice Address - Phone:772-589-2043
Practice Address - Fax:772-388-2628
Is Sole Proprietor?:No
Enumeration Date:2020-10-22
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS27844183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist