MEDICARE: DR. KIM YVETTE WILSON PHARMD, RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	03-01-24593	OH
2	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	PS 45552	FL

General Provider Information

NPI Number	:	1073532438
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KIM YVETTE WILSON PHARMD, RPH

Provider Business Mailing Address
First Line	:	10117 PALERMO CIR
Second Line	:	APARTMENT 203
City	:	TAMPA
State	:	FL
Zip	:	33619-5080
Country	:	US
Telephone Number	:	813-620-3765
Fax Number	:	813-620-3765

Provider Business Practice Location Address
First Line	:	3800 FLETCHER AVE
Second Line	:	SUITE 133
City	:	TAMPA
State	:	FL
Zip	:	33613
Country	:	US
Telephone Number	:	813-975-6500
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/18/2006
Last Update Date	:	02/01/2011

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