Provider Demographics
NPI:1154159325
Name:WILSON, DREW
Entity type:Individual
Prefix:
First Name:DREW
Middle Name:
Last Name:WILSON
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 1:626 N 30TH ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23223-6637
Mailing Address - Country:US
Mailing Address - Phone:540-622-3532
Mailing Address - Fax:
Practice Address - Street 1:1201 BROAD ROCK BLVD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23249-0001
Practice Address - Country:US
Practice Address - Phone:804-675-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-22
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202222116183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist