Healthcare Provider Details

I. General information

NPI: 1568761088
Provider Name (Legal Business Name): ADRIAN SHAWN REID WILSON PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2011
Last Update Date: 04/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 CRYSTAL SPRING AVE SW STE 110
ROANOKE VA
24014-2465
US

IV. Provider business mailing address

2001 CRYSTAL SPRING AVE SW STE 110
ROANOKE VA
24014-2465
US

V. Phone/Fax

Practice location:
  • Phone: 540-676-7053
  • Fax: 540-853-0910
Mailing address:
  • Phone: 540-676-7053
  • Fax: 540-853-0910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202210034
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: