MEDICARE: JEFFREY ALLEN WILSON PHARMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	68748	TX

General Provider Information

NPI Number	:	1558034462
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFREY ALLEN WILSON PHARMD

Provider Business Mailing Address
First Line	:	1029 PALO DURO TRL
Second Line	:
City	:	KELLER
State	:	TX
Zip	:	76248-4984
Country	:	US
Telephone Number	:	817-789-3020
Fax Number	:

Provider Business Practice Location Address
First Line	:	6984 RUFE SNOW DR
Second Line	:
City	:	NORTH RICHLAND HILLS
State	:	TX
Zip	:	76148-2356
Country	:	US
Telephone Number	:	817-427-9353
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/27/2021
Last Update Date	:	07/27/2021

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