Provider Demographics
NPI:1033198205
Name:WILDER, CARLA J (RPH)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:J
Last Name:WILDER
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 1:719 BROOKSIDE LN
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44067-3083
Mailing Address - Country:US
Mailing Address - Phone:216-636-0762
Mailing Address - Fax:
Practice Address - Street 1:2070 E 90TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-2971
Practice Address - Country:US
Practice Address - Phone:216-636-0762
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-2-18095183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist