Healthcare Provider Details

I. General information

NPI: 1003449851
Provider Name (Legal Business Name): RACHEL OCTAVIA WYLIE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2020
Last Update Date: 02/20/2020
Certification Date: 02/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1226 MULBERRY ST
MOUNT VERNON IN
47620-1358
US

IV. Provider business mailing address

1226 MULBERRY ST
MOUNT VERNON IN
47620-1358
US

V. Phone/Fax

Practice location:
  • Phone: 618-218-6502
  • Fax:
Mailing address:
  • Phone: 618-218-6502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051301509
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26028287A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: