Provider Demographics
NPI:1962785667
Name:WILSON, DALLAS (RPH, PHARMD)
Entity type:Individual
Prefix:MRS
First Name:DALLAS
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:RPH, PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4292 SPYGLASS HL
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-2397
Mailing Address - Country:US
Mailing Address - Phone:513-254-7457
Mailing Address - Fax:
Practice Address - Street 1:1090 HIGH ST
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45011-6013
Practice Address - Country:US
Practice Address - Phone:513-868-1667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03328822183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist