Healthcare Provider Details

I. General information

NPI: 1740863323
Provider Name (Legal Business Name): AMBER WILSON PAUL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2021
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

461 S COLUMBIA AVE
RINCON GA
31326-9446
US

IV. Provider business mailing address

230 DEAN DR
GUYTON GA
31312-4455
US

V. Phone/Fax

Practice location:
  • Phone: 912-584-7140
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number030112
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: