MEDICARE: DR. CHARLES CHRISTIAN WILSON III PHARM.D

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	11874	NV

General Provider Information

NPI Number	:	1518249424
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES CHRISTIAN WILSON III PHARM.D

Provider Business Mailing Address
First Line	:	3240 IVORY COAST DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-2269
Country	:	US
Telephone Number	:	702-643-4426
Fax Number	:

Provider Business Practice Location Address
First Line	:	3240 IVORY COAST DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-2269
Country	:	US
Telephone Number	:	702-643-4426
Fax Number	:

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

Provider Enumeration Date	:	09/16/2011
Last Update Date	:	09/16/2011

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