Healthcare Provider Details

I. General information

NPI: 1053922195
Provider Name (Legal Business Name): NATHANIEL WILSON PHARM D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2020
Last Update Date: 08/13/2020
Certification Date: 08/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

429 N STATE OF FRANKLIN RD
JOHNSON CITY TN
37604-6034
US

IV. Provider business mailing address

429 N STATE OF FRANKLIN RD
JOHNSON CITY TN
37604-6034
US

V. Phone/Fax

Practice location:
  • Phone: 423-975-0068
  • Fax: 423-975-0061
Mailing address:
  • Phone: 423-975-0068
  • Fax: 423-975-0061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number0000042121
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: