MEDICARE: KEVIN LANE WILSON RPH

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	PS0017762	FL

General Provider Information

NPI Number	:	1558608422
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN LANE WILSON RPH

Provider Business Mailing Address
First Line	:	14444 BEACH BLVD STE 6
Second Line	:	PUBLIX PHARMACY #433
City	:	JACKSONVILLE
State	:	FL
Zip	:	32250-2010
Country	:	US
Telephone Number	:	904-223-0423
Fax Number	:	904-223-3316

Provider Business Practice Location Address
First Line	:	14444 BEACH BLVD STE 6
Second Line	:	PUBLIX PHARMACY #433
City	:	JACKSONVILLE
State	:	FL
Zip	:	32250-2010
Country	:	US
Telephone Number	:	904-223-0423
Fax Number	:	904-223-3316

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

Provider Enumeration Date	:	01/11/2013
Last Update Date	:	01/11/2013

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