1245577071 NPI number — WILSON PHARMACY INC

Table of content: (NPI 1245577071)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245577071 NPI number — WILSON PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILSON PHARMACY INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BALLAD HEALTH PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245577071
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/10/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
311 PRINCETON RD SUITE 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOHNSON CITY
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37601-2026
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
276-258-1990
Provider Business Mailing Address Fax Number:
276-258-1999

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16000 JOHNSTON MEMORIAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ABINGDON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24211-7664
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-258-1990
Provider Business Practice Location Address Fax Number:
276-258-1999
Provider Enumeration Date:
01/14/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KILGORE
Authorized Official First Name:
CARL
Authorized Official Middle Name:
STEVEN
Authorized Official Title or Position:
SVP
Authorized Official Telephone Number:
423-915-5185

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  0201004496 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)