Provider Demographics
NPI:1942901392
Name:WILSON, EILEEN
Entity type:Individual
Prefix:
First Name:EILEEN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 RONKONKOMA AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-3339
Mailing Address - Country:US
Mailing Address - Phone:631-981-4477
Mailing Address - Fax:631-981-5225
Practice Address - Street 1:139 RONKONKOMA AVE
Practice Address - Street 2:
Practice Address - City:LAKE RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-3339
Practice Address - Country:US
Practice Address - Phone:631-981-4477
Practice Address - Fax:631-981-5225
Is Sole Proprietor?:No
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician