Healthcare Provider Details

I. General information

NPI: 1073532438
Provider Name (Legal Business Name): KIM YVETTE WILSON PHARMD, RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 02/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 FLETCHER AVE SUITE 133
TAMPA FL
33613
US

IV. Provider business mailing address

10117 PALERMO CIR APARTMENT 203
TAMPA FL
33619-5080
US

V. Phone/Fax

Practice location:
  • Phone: 813-975-6500
  • Fax:
Mailing address:
  • Phone: 813-620-3765
  • Fax: 813-620-3765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03-01-24593
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberPS 45552
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: