Provider Demographics
NPI:1235562497
Name:WILDE, LEON (RPH)
Entity Type:Individual
Prefix:MR
First Name:LEON
Middle Name:
Last Name:WILDE
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 1:703 PORTWALK PL
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94065-1811
Mailing Address - Country:US
Mailing Address - Phone:650-594-4955
Mailing Address - Fax:
Practice Address - Street 1:703 PORTWALK PL
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94065-1811
Practice Address - Country:US
Practice Address - Phone:650-594-4955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-12
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32563183500000X
NY22769183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
080301052OtherMAY'S SS