Provider Demographics
NPI:1699510636
Name:WILSON, KEISHA (RPH)
Entity type:Individual
Prefix:
First Name:KEISHA
Middle Name:
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 1:16615 COUNTY ROAD 21
Mailing Address - Street 2:
Mailing Address - City:MARION JUNCTION
Mailing Address - State:AL
Mailing Address - Zip Code:36759-4240
Mailing Address - Country:US
Mailing Address - Phone:334-431-2028
Mailing Address - Fax:
Practice Address - Street 1:1631 BROAD ST
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:AL
Practice Address - Zip Code:36701-4202
Practice Address - Country:US
Practice Address - Phone:334-872-2326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL13445183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist