Provider Demographics
NPI:1093956260
Name:WILSON, KEVIN M (RPH)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
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 1:116 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WALLACE
Mailing Address - State:NC
Mailing Address - Zip Code:28466-2720
Mailing Address - Country:US
Mailing Address - Phone:910-285-8737
Mailing Address - Fax:910-285-8550
Practice Address - Street 1:116 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WALLACE
Practice Address - State:NC
Practice Address - Zip Code:28466-2720
Practice Address - Country:US
Practice Address - Phone:910-285-8737
Practice Address - Fax:910-285-8550
Is Sole Proprietor?:No
Enumeration Date:2009-03-17
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8972183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist