Provider Demographics
NPI:1215280458
Name:WILSON, JAMES OLIN JR (RPH)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:OLIN
Last Name:WILSON
Suffix:JR
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2757 SAWGRASS LN
Mailing Address - Street 2:
Mailing Address - City:PHENIX CITY
Mailing Address - State:AL
Mailing Address - Zip Code:36867-2038
Mailing Address - Country:US
Mailing Address - Phone:334-214-4734
Mailing Address - Fax:
Practice Address - Street 1:2940 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-1152
Practice Address - Country:US
Practice Address - Phone:334-677-6149
Practice Address - Fax:334-677-6189
Is Sole Proprietor?:No
Enumeration Date:2012-10-25
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL11530183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist