Provider Demographics
NPI:1962055053
Name:WILSON, AMANDA C (RPH)
Entity type:Individual
Prefix:
First Name:AMANDA
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 1:1009 KERN LN
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39059-8765
Mailing Address - Country:US
Mailing Address - Phone:601-906-7887
Mailing Address - Fax:
Practice Address - Street 1:113 BO BO DR
Practice Address - Street 2:
Practice Address - City:CRYSTAL SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39059-2741
Practice Address - Country:US
Practice Address - Phone:601-892-4121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-18
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-08901183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist