MEDICARE: MICHAEL PAUL WILSON PHARMACIST

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	37177	TX
2	183500000X	Pharmacist	16146	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	37177	OTHER	TX	STATE OF TEXAS BOARD OF PHARMACY

General Provider Information

NPI Number	:	1467776377
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL PAUL WILSON PHARMACIST

Provider Business Mailing Address
First Line	:	4520 W 7TH ST
Second Line	:
City	:	WAKE VILLAGE
State	:	TX
Zip	:	75501-6354
Country	:	US
Telephone Number	:	903-838-7539
Fax Number	:	903-832-9055

Provider Business Practice Location Address
First Line	:	4520 W 7TH ST
Second Line	:
City	:	WAKE VILLAGE
State	:	TX
Zip	:	75501-6354
Country	:	US
Telephone Number	:	903-838-7539
Fax Number	:	903-832-9055

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

Provider Enumeration Date	:	03/22/2010
Last Update Date	:	03/22/2010

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