Provider Demographics
NPI:1447528286
Name:WILSON, MICHELLE J (RPH)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:J
Last Name:WILSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:J
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:1066 LAUREL CREEK DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-9607
Mailing Address - Country:US
Mailing Address - Phone:219-921-0565
Mailing Address - Fax:
Practice Address - Street 1:1066 LAUREL CREEK DR
Practice Address - Street 2:
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-9607
Practice Address - Country:US
Practice Address - Phone:219-921-0565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-07
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26017724A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist