Healthcare Provider Details

I. General information

NPI: 1336422617
Provider Name (Legal Business Name): DARYEL C. WILSON RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2011
Last Update Date: 09/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18301 PULASKI RD.
HAZEL CREST IL
60429
US

IV. Provider business mailing address

PO BOX 2311
COUNTRY CLUB HILLS IL
60478-9411
US

V. Phone/Fax

Practice location:
  • Phone: 708-335-4180
  • Fax: 708-335-4271
Mailing address:
  • Phone: 708-922-3928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number015.039662
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1835X0200X
TaxonomyOncology Pharmacist
License Number051.039662
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: