Provider Demographics
NPI:1194233643
Name:WILSON, MATTHEW CLARK (PHARMD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:CLARK
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 1:6555 QUINCE RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-8202
Mailing Address - Country:US
Mailing Address - Phone:901-515-5600
Mailing Address - Fax:901-515-5658
Practice Address - Street 1:6555 QUINCE RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-8202
Practice Address - Country:US
Practice Address - Phone:901-515-5600
Practice Address - Fax:901-515-5658
Is Sole Proprietor?:No
Enumeration Date:2018-01-18
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7706183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist