Healthcare Provider Details

I. General information

NPI: 1447889100
Provider Name (Legal Business Name): JESSICA WILSON PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2020
Last Update Date: 04/05/2020
Certification Date: 04/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2728 E MAIN ST
SPRINGFIELD OH
45503-5117
US

IV. Provider business mailing address

2728 E MAIN ST
SPRINGFIELD OH
45503-5117
US

V. Phone/Fax

Practice location:
  • Phone: 937-525-6770
  • Fax: 937-525-6734
Mailing address:
  • Phone: 937-525-6770
  • Fax: 937-525-6734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number03237242
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: