Healthcare Provider Details

I. General information

NPI: 1922262914
Provider Name (Legal Business Name): BRENNA ELAINE WILSON PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2008
Last Update Date: 07/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 OLLIE AVE
CLANTON AL
35045-2238
US

IV. Provider business mailing address

640 OLLIE AVE
CLANTON AL
35045-2238
US

V. Phone/Fax

Practice location:
  • Phone: 205-755-1711
  • Fax: 205-755-9601
Mailing address:
  • Phone: 205-755-1711
  • Fax: 205-755-9601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number15851
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: