Basic Information
| Provider Information | |||||||||
| NPI: | 1821099086 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | BRENDA | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | RPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 108 PATRICK HENRY CT | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404221788 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592360508 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 217 S 3RD ST | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404221823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592391000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 9160 | KY | Y | Pharmacy Service Providers | Pharmacist | 183500000X | 8487 | NC | N | Pharmacy Service Providers | Pharmacist |
No ID Information.