Provider Demographics
NPI:1336422617
Name:WILSON, DARYEL C (RPH)
Entity type:Individual
Prefix:MS
First Name:DARYEL
Middle Name:C
Last Name:WILSON
Suffix:
Gender:F
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:PO BOX 2311
Mailing Address - Street 2:
Mailing Address - City:COUNTRY CLUB HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60478-9411
Mailing Address - Country:US
Mailing Address - Phone:708-922-3928
Mailing Address - Fax:
Practice Address - Street 1:18301 PULASKI RD.
Practice Address - Street 2:
Practice Address - City:HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429
Practice Address - Country:US
Practice Address - Phone:708-335-4180
Practice Address - Fax:708-335-4271
Is Sole Proprietor?:No
Enumeration Date:2011-09-23
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL015.039662183500000X
IL051.0396621835X0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835X0200XPharmacy Service ProvidersPharmacistOncology