Provider Demographics
NPI:1134402316
Name:WILSON, DEBRA L (RPH)
Entity type:Individual
Prefix:MS
First Name:DEBRA
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4010 W LAWRENCE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630
Mailing Address - Country:US
Mailing Address - Phone:773-286-0309
Mailing Address - Fax:773-286-2645
Practice Address - Street 1:4010 W LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630
Practice Address - Country:US
Practice Address - Phone:773-286-0309
Practice Address - Fax:773-286-2645
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-23
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051040518183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist