Healthcare Provider Details

I. General information

NPI: 1194019042
Provider Name (Legal Business Name): ANGELA WILKERSON RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2011
Last Update Date: 01/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 THF BLVD
CHESTERFIELD MO
63005-1150
US

IV. Provider business mailing address

3750 STATE ROUTE 15
FREEBURG IL
62243-1908
US

V. Phone/Fax

Practice location:
  • Phone: 636-536-6215
  • Fax:
Mailing address:
  • Phone: 618-977-8719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2010033108
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: