=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861403446
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILSON PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2006
-----------------------------------------------------
Last Update Date | 04/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1657 E STONE DR STE A
-----------------------------------------------------
City | KINGSPORT
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37660-4669
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-247-2126
-----------------------------------------------------
Fax | 423-247-2138
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 311 PRINCETON RD SUITE 1
-----------------------------------------------------
City | JOHNSON CITY
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37601-2026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-247-2126
-----------------------------------------------------
Fax | 423-247-2138
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EVP/CFO
-----------------------------------------------------
Name | SHANE EDWIN HILTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 423-302-3467
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 0000003075
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------