=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396815262
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILSON'S PHARMACY OF CANTON, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2006
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 231 RIVERSTONE PKWY SUITE 107
-----------------------------------------------------
City | CANTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30114-2463
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-720-7450
-----------------------------------------------------
Fax | 770-479-4443
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 231 RIVERSTONE PKWY SUITE 107
-----------------------------------------------------
City | CANTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30114-2463
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-720-7450
-----------------------------------------------------
Fax | 770-479-4443
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. TIM WILSON
-----------------------------------------------------
Credential | R.PH
-----------------------------------------------------
Telephone | 770-720-7450
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PHRE007502
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------