Healthcare Provider Details

I. General information

NPI: 1275540304
Provider Name (Legal Business Name): JO NELL WILKINSON & WILLIAM JACK WILKINSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 09/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 MYER LN
KERMIT TX
79745-4634
US

IV. Provider business mailing address

PO BOX 947
MENARD TX
76859-0947
US

V. Phone/Fax

Practice location:
  • Phone: 432-586-2556
  • Fax: 432-586-5934
Mailing address:
  • Phone: 325-396-4630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number15496
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number15496
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number25598
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number15496
License Number StateTX

VIII. Authorized Official

Name: MRS. JO NELL WILKINSON
Title or Position: OWNER/PHARMACIST
Credential: RPH
Phone: 325-396-4630