Provider Demographics
NPI:1285971234
Name:WILSON, JONATHAN MARK (PHARMD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:MARK
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 1:500 SYCAMORE LN
Mailing Address - Street 2:APT 207
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-7319
Mailing Address - Country:US
Mailing Address - Phone:770-548-8986
Mailing Address - Fax:
Practice Address - Street 1:120 PROMINENCE POINT PKWY
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-9008
Practice Address - Country:US
Practice Address - Phone:770-720-4825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-10
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH026795183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist