Provider Demographics
NPI:1962121103
Name:WILSON, KENNETH WAYNE (RPH)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:WAYNE
Last Name:WILSON
Suffix:
Gender:M
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:PO BOX 99
Mailing Address - Street 2:
Mailing Address - City:MARKSVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71351-0099
Mailing Address - Country:US
Mailing Address - Phone:318-253-8747
Mailing Address - Fax:
Practice Address - Street 1:134 LA RUE MEDECINE ST
Practice Address - Street 2:
Practice Address - City:MARKSVILLE
Practice Address - State:LA
Practice Address - Zip Code:71351-2637
Practice Address - Country:US
Practice Address - Phone:318-253-8747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-23
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA136811835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care