Healthcare Provider Details

I. General information

NPI: 1336453547
Provider Name (Legal Business Name): JENNIFER ASHLEY WILSON PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNIFER ASHLEY WAITZMAN PHARM.D.

II. Dates (important events)

Enumeration Date: 07/29/2010
Last Update Date: 04/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 N. MAIN ST.
WINGATE NC
28174
US

IV. Provider business mailing address

515 N. MAIN ST.
WINGATE NC
28174-5729
US

V. Phone/Fax

Practice location:
  • Phone: 704-233-8964
  • Fax: 704-233-8332
Mailing address:
  • Phone: 704-233-8964
  • Fax: 702-233-8332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number21391
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: