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General NPI Number Information
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NPI Number | 1144507609
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Entity Type | Individual
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Provider Name | STEVE LARRY WILSON JR. PHARMD
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Gender | Male
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Dates
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Enumeration Date | 11/12/2011
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Last Update Date | 06/27/2022
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Provider Practice Location Address
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Address Line | 5101 BEATLINE ROAD
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City | LONG BEACH
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State | MS
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Zip | 39560
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Country | US
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Telephone | 228-424-5579
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Fax |
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Provider Business Mailing Address
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Address Line | 5101 BEATLINE ROAD
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City | LONG BEACH
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State | MS
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Zip | 39560-6610
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Country | US
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Telephone | 228-424-5579
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | E-08636
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License Number State | MS
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