Provider Demographics
NPI:1215671664
Name:WILSON, ANDREA BLAINE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:BLAINE
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 1:10451 S 240TH WEST AVE
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-1527
Mailing Address - Country:US
Mailing Address - Phone:918-693-7357
Mailing Address - Fax:
Practice Address - Street 1:6606 E 81ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-4247
Practice Address - Country:US
Practice Address - Phone:918-524-1435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-22
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK19615183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist