Provider Demographics
NPI:1053611699
Name:WILSON, MARK LEO (PHARMD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:LEO
Last Name:WILSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5049 S 13TH ST
Mailing Address - Street 2:
Mailing Address - City:LEAVENWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:66048-5581
Mailing Address - Country:US
Mailing Address - Phone:913-727-4810
Mailing Address - Fax:
Practice Address - Street 1:5049 S 13TH ST
Practice Address - Street 2:
Practice Address - City:LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66048-5581
Practice Address - Country:US
Practice Address - Phone:913-727-4810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-29
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE9433183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist