Provider Demographics
NPI:1326344334
Name:WIGLEY, BRUCE (RPH)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:WIGLEY
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 1:625 AMBERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-5529
Mailing Address - Country:US
Mailing Address - Phone:574-534-3160
Mailing Address - Fax:
Practice Address - Street 1:1755 LINCOLNWAY E
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-6425
Practice Address - Country:US
Practice Address - Phone:574-533-4932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-09
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26015072A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist