Healthcare Provider Details

I. General information

NPI: 1770195596
Provider Name (Legal Business Name): DR. BRENDON WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2020
Last Update Date: 08/21/2020
Certification Date: 08/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E MAIN ST
WILLOW SPRINGS MO
65793-1413
US

IV. Provider business mailing address

PO BOX 278
WILLOW SPRINGS MO
65793-0278
US

V. Phone/Fax

Practice location:
  • Phone: 417-469-3005
  • Fax:
Mailing address:
  • Phone: 417-293-9546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2015027180
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: