Provider Demographics
NPI:1538264502
Name:WILSON, LYNN BUTCHER (PD)
Entity type:Individual
Prefix:
First Name:LYNN
Middle Name:BUTCHER
Last Name:WILSON
Suffix:
Gender:F
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:908 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:FORDYCE
Mailing Address - State:AR
Mailing Address - Zip Code:71742-2216
Mailing Address - Country:US
Mailing Address - Phone:870-352-2161
Mailing Address - Fax:870-352-3236
Practice Address - Street 1:908 W 4TH ST
Practice Address - Street 2:
Practice Address - City:FORDYCE
Practice Address - State:AR
Practice Address - Zip Code:71742-2216
Practice Address - Country:US
Practice Address - Phone:870-352-2161
Practice Address - Fax:870-352-3236
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD07527183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist