Provider Demographics
NPI:1316543846
Name:WILSON, EMILY SUE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:EMILY
Middle Name:SUE
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:PO BOX 102
Mailing Address - Street 2:
Mailing Address - City:PIASA
Mailing Address - State:IL
Mailing Address - Zip Code:62079-0102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:303 S STATE ST
Practice Address - Street 2:
Practice Address - City:JERSEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62052-1852
Practice Address - Country:US
Practice Address - Phone:618-498-1144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-09
Last Update Date:2020-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.302265183500000X
MO2019034281183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist