Healthcare Provider Details

I. General information

NPI: 1457573305
Provider Name (Legal Business Name): LINDA MARIE SEWELL WILSON RPH, PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LINDA MARIE SEWELL WILSON PHARM D, RPH

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 06/27/2026
Certification Date: 06/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 W LAKE AVE STE 1A
PEORIA IL
61614-5995
US

IV. Provider business mailing address

801 W LAKE AVE STE 1A
PEORIA IL
61614-5995
US

V. Phone/Fax

Practice location:
  • Phone: 309-682-2983
  • Fax: 309-682-3128
Mailing address:
  • Phone: 309-682-2983
  • Fax: 309-682-3128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number051290140
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051290140
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: