Healthcare Provider Details

I. General information

NPI: 1407478522
Provider Name (Legal Business Name): WILSON PHARMACY GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2020
Last Update Date: 10/18/2021
Certification Date: 10/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 N MAIN
LOCKNEY TX
79241
US

IV. Provider business mailing address

PO BOX 685
LOCKNEY TX
79241-0685
US

V. Phone/Fax

Practice location:
  • Phone: 806-652-3353
  • Fax: 806-652-2118
Mailing address:
  • Phone: 806-652-3353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DR. BRANCE WILSON
Title or Position: OWNER
Credential: PHARMD
Phone: 806-652-3353