Provider Demographics
NPI:1396029989
Name:WILSON, JASON SHANE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:SHANE
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 1:43250 SOUTHERN WALK PLZ
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20148-4462
Mailing Address - Country:US
Mailing Address - Phone:703-729-0693
Mailing Address - Fax:703-723-2876
Practice Address - Street 1:43250 SOUTHERN WALK PLZ
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20148-4462
Practice Address - Country:US
Practice Address - Phone:703-729-0693
Practice Address - Fax:703-723-2876
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-01
Last Update Date:2011-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202210696183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist