Provider Demographics
NPI:1285915207
Name:WILSON, JEB AARON (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JEB
Middle Name:AARON
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 1:1047 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54022-1596
Mailing Address - Country:US
Mailing Address - Phone:715-426-4089
Mailing Address - Fax:715-426-4095
Practice Address - Street 1:1047 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54022-1596
Practice Address - Country:US
Practice Address - Phone:715-426-4089
Practice Address - Fax:715-426-4095
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-03
Last Update Date:2011-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN116975183500000X
WI14870183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist