Provider Demographics
NPI:1205424967
Name:WILSON, HOLLY REBECCA
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:REBECCA
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15885 KARI LN
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:TX
Mailing Address - Zip Code:76579-3522
Mailing Address - Country:US
Mailing Address - Phone:254-541-4692
Mailing Address - Fax:
Practice Address - Street 1:1412 N VALLEY MILLS DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-4461
Practice Address - Country:US
Practice Address - Phone:254-761-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-07
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX104608183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician