Provider Demographics
NPI:1366932477
Name:WILSON, SHAKIA
Entity type:Individual
Prefix:
First Name:SHAKIA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6104 OLD BRANCH AVE
Mailing Address - Street 2:
Mailing Address - City:TEMPLE HILLS
Mailing Address - State:MD
Mailing Address - Zip Code:20748-2557
Mailing Address - Country:US
Mailing Address - Phone:301-702-6175
Mailing Address - Fax:
Practice Address - Street 1:6104 OLD BRANCH AVE
Practice Address - Street 2:
Practice Address - City:TEMPLE HILLS
Practice Address - State:MD
Practice Address - Zip Code:20748-2557
Practice Address - Country:US
Practice Address - Phone:301-702-6175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-14
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDT13475183700000X
MD10049912183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD10049912OtherPTCB/CPHT