Provider Demographics
NPI:1972886067
Name:WILSON, KENNETH L
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:L
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4398 ATLANTA HWY
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-7314
Mailing Address - Country:US
Mailing Address - Phone:678-639-0129
Mailing Address - Fax:678-639-1547
Practice Address - Street 1:4398 ATLANTA HWY
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-7314
Practice Address - Country:US
Practice Address - Phone:678-639-0129
Practice Address - Fax:678-639-1547
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-24
Last Update Date:2011-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10952183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist