Provider Demographics
NPI:1194112185
Name:WILSON, NICOLE MICHELE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:MICHELE
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GARDNER
Mailing Address - State:KS
Mailing Address - Zip Code:66030-1744
Mailing Address - Country:US
Mailing Address - Phone:913-884-7912
Mailing Address - Fax:
Practice Address - Street 1:750 E MAIN ST
Practice Address - Street 2:
Practice Address - City:GARDNER
Practice Address - State:KS
Practice Address - Zip Code:66030-1744
Practice Address - Country:US
Practice Address - Phone:913-884-7912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-17
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-16610183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist