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General NPI Number Information
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NPI Number | 1861487340
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Entity Type | Individual
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Provider Name | JUSTIN BLAKE WILSON PHARM.D.
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Gender | Male
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Dates
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Enumeration Date | 09/12/2005
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1212A S DOUGLAS BLVD
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City | MIDWEST CITY
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State | OK
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Zip | 73130-5213
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Country | US
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Telephone | 405-741-1200
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Fax | 405-741-1224
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Provider Business Mailing Address
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Address Line | 3025 ELIE ST
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City | NORMAN
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State | OK
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Zip | 73072-1964
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Country | US
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Telephone | 405-701-5970
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Fax | 405-741-1224
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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 | 13059
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License Number State | OK
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