Provider Demographics
NPI:1548860265
Name:WILSON, CLINTON BRAD
Entity type:Individual
Prefix:
First Name:CLINTON
Middle Name:BRAD
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 HIAWATHA FARMS RD
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:FL
Mailing Address - Zip Code:32344-0821
Mailing Address - Country:US
Mailing Address - Phone:850-728-2562
Mailing Address - Fax:
Practice Address - Street 1:650 HIAWATHA FARMS RD
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:FL
Practice Address - Zip Code:32344-0821
Practice Address - Country:US
Practice Address - Phone:850-728-2562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-30
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS37926183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist