Provider Demographics
NPI:1134750748
Name:WILSON, KEVIN ROBERT (DOCTOR OF PHARMACY)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:ROBERT
Last Name:WILSON
Suffix:
Gender:M
Credentials:DOCTOR OF PHARMACY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4995 HIGHLAND RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328-1143
Mailing Address - Country:US
Mailing Address - Phone:248-674-2261
Mailing Address - Fax:248-674-1027
Practice Address - Street 1:4995 HIGHLAND RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-1143
Practice Address - Country:US
Practice Address - Phone:248-674-2261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-01
Last Update Date:2020-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5315098302183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist