Provider Demographics
NPI:1003284522
Name:WIGMOSTA, ERIC (PHARMD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:WIGMOSTA
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5506 N ROAD 68
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-9627
Mailing Address - Country:US
Mailing Address - Phone:509-547-1789
Mailing Address - Fax:
Practice Address - Street 1:5506 N ROAD 68
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-9627
Practice Address - Country:US
Practice Address - Phone:509-547-1789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-14
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60557087183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist