=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497178941
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN ROBERT WILSON JR. R.PH.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2014
-----------------------------------------------------
Last Update Date | 02/03/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1206 W CAMPUS DR
-----------------------------------------------------
City | TEMPLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76502-7124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-298-6144
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1206 W CAMPUS DR
-----------------------------------------------------
City | TEMPLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76502-7124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-298-6144
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1835P0018X
-----------------------------------------------------
Taxonomy Name | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
-----------------------------------------------------
License Number | 34911
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------