Basic Information
Provider Information
NPI: 1013261387
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: WILLS
FirstName: ANDREW
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 10C BEAVER CT
Address2:  
City: WILKES BARRE
State: PA
PostalCode: 187027897
CountryCode: US
TelephoneNumber: 5708243521
FaxNumber:  
Practice Location
Address1: 1111 E END BLVD
Address2:  
City: WILKES BARRE
State: PA
PostalCode: 187110030
CountryCode: US
TelephoneNumber: 5708243521
FaxNumber:  
Other Information
ProviderEnumerationDate: 11/07/2012
LastUpdateDate: 11/07/2012
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
183500000X28RI03535200NJY Pharmacy Service ProvidersPharmacist 

No ID Information.


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