Provider Demographics
NPI:1902949555
Name:WILSON, LAURA KATHERINE (RPH)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:KATHERINE
Last Name:WILSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2692 MAZATLAN DR
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81506-1790
Mailing Address - Country:US
Mailing Address - Phone:970-255-5803
Mailing Address - Fax:970-255-5805
Practice Address - Street 1:2800 D RD
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-4721
Practice Address - Country:US
Practice Address - Phone:970-255-5803
Practice Address - Fax:970-255-5805
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO111681835P1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1300XPharmacy Service ProvidersPharmacistPsychiatric