1962539536 NPI number — MR. JOHN ROBERT WILSON R.PH.

Table of content: MR. ERIC W FLACH MD (NPI 1215996939)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962539536 NPI number — MR. JOHN ROBERT WILSON R.PH.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
JOHN
Provider Middle Name:
ROBERT
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
R.PH.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1962539536
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/29/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
341 WALKER CHAPEL PLZ STE 109
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FULTONDALE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35068-3404
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-502-1010
Provider Business Mailing Address Fax Number:
866-228-0184

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1528 CARRAWAY BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BIRMINGHAM
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35234-1998
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-502-1010
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  10123 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100002687 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0115281 . This is a "NCPDP NUMBER" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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