Provider Demographics
NPI:1679816268
Name:WILSON, TIMOTHY J (RPH)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:WILSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6824 REINHARDT COLLEGE PKWY
Mailing Address - Street 2:
Mailing Address - City:WALESKA
Mailing Address - State:GA
Mailing Address - Zip Code:30183-3266
Mailing Address - Country:US
Mailing Address - Phone:770-479-2172
Mailing Address - Fax:
Practice Address - Street 1:6824 REINHARDT COLLEGE PKWY
Practice Address - Street 2:
Practice Address - City:WALESKA
Practice Address - State:GA
Practice Address - Zip Code:30183-3266
Practice Address - Country:US
Practice Address - Phone:770-479-2172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-01
Last Update Date:2013-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA014851183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist