Provider Demographics
NPI:1912343492
Name:WILDER, ALYSON GIBSON (PHARMD, BCPS)
Entity type:Individual
Prefix:
First Name:ALYSON
Middle Name:GIBSON
Last Name:WILDER
Suffix:
Gender:F
Credentials:PHARMD, BCPS
Other - Prefix:
Other - First Name:ALYSON
Other - Middle Name:WRAE
Other - Last Name:GIBSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARMD, BCPS
Mailing Address - Street 1:13925 FISH EAGLE DR E
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32226-5894
Mailing Address - Country:US
Mailing Address - Phone:803-645-9272
Mailing Address - Fax:
Practice Address - Street 1:13925 FISH EAGLE DR E
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32226-5894
Practice Address - Country:US
Practice Address - Phone:803-645-9272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-10
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC120851835P0018X
MD192951835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist