Healthcare Provider Details

I. General information

NPI: 1619220175
Provider Name (Legal Business Name): DAVID ALAN WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2012
Last Update Date: 10/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 E WALL ST
EAGLE RIVER WI
54521-8720
US

IV. Provider business mailing address

PO BOX 1059
EAGLE RIVER WI
54521-1059
US

V. Phone/Fax

Practice location:
  • Phone: 715-479-6413
  • Fax: 715-479-4621
Mailing address:
  • Phone: 715-479-4613
  • Fax: 715-479-4621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number10409-40
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: