Provider Demographics
NPI:1124628623
Name:WILSON, GREGORY (PHARMD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 CRESCENT BLVD
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-2419
Mailing Address - Country:US
Mailing Address - Phone:208-869-1890
Mailing Address - Fax:
Practice Address - Street 1:212 NORTHSIDE DR
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201-1723
Practice Address - Country:US
Practice Address - Phone:802-442-6822
Practice Address - Fax:802-442-8356
Is Sole Proprietor?:No
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT033.0088946183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist