MEDICARE: MR. JOHN ROBERT WILSON R.PH.

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	10123	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	0115281	OTHER	AL	NCPDP NUMBER

General Provider Information

NPI Number	:	1962539536
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN ROBERT WILSON R.PH.

Provider Business Mailing Address
First Line	:	341 WALKER CHAPEL PLZ STE 109
Second Line	:
City	:	FULTONDALE
State	:	AL
Zip	:	35068-3404
Country	:	US
Telephone Number	:	205-502-1010
Fax Number	:	866-228-0184

Provider Business Practice Location Address
First Line	:	1528 CARRAWAY BLVD
Second Line	:
City	:	BIRMINGHAM
State	:	AL
Zip	:	35234-1998
Country	:	US
Telephone Number	:	205-502-1010
Fax Number	:

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

Provider Enumeration Date	:	02/28/2007
Last Update Date	:	12/29/2017

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