Provider Demographics
NPI:1346929320
Name:WILDE, SAMUEL MICHAEL (PHARMD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:MICHAEL
Last Name:WILDE
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 1:340 FALCON RIDGE PKWY STE 403
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:NV
Mailing Address - Zip Code:89027-8851
Mailing Address - Country:US
Mailing Address - Phone:435-668-8867
Mailing Address - Fax:
Practice Address - Street 1:340 FALCON RIDGE PKWY STE 403
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:NV
Practice Address - Zip Code:89027-8851
Practice Address - Country:US
Practice Address - Phone:435-668-8867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9765691-1701183500000X
NV23475183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist