Provider Demographics
NPI:1144507609
Name:WILSON, STEVE LARRY JR (PHARMD)
Entity type:Individual
Prefix:DR
First Name:STEVE
Middle Name:LARRY
Last Name:WILSON
Suffix:JR
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 1:5101 BEATLINE ROAD
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:MS
Mailing Address - Zip Code:39560-6610
Mailing Address - Country:US
Mailing Address - Phone:228-424-5579
Mailing Address - Fax:
Practice Address - Street 1:5101 BEATLINE ROAD
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:MS
Practice Address - Zip Code:39560
Practice Address - Country:US
Practice Address - Phone:228-424-5579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-12
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-08636183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist