Provider Demographics
NPI:1073783072
Name:WILD, STEPHEN J (RPH)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:J
Last Name:WILD
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5TH & ROOSEVELT BLDG 37 NW CORNER
Mailing Address - Street 2:GL-CMOP
Mailing Address - City:HINES
Mailing Address - State:IL
Mailing Address - Zip Code:60141-5221
Mailing Address - Country:US
Mailing Address - Phone:708-786-4397
Mailing Address - Fax:
Practice Address - Street 1:5TH & ROOSEVELT BLDG 37 NW CORNER
Practice Address - Street 2:DEPARTMENT OF VETERANS AFFAIRS, GL-CMOP
Practice Address - City:HINES
Practice Address - State:IL
Practice Address - Zip Code:60141-5221
Practice Address - Country:US
Practice Address - Phone:708-786-4397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-05
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist