Provider Demographics
NPI:1477154375
Name:WILDERMUTH, MICHAEL TRAVIS (RPH)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:TRAVIS
Last Name:WILDERMUTH
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 1:6213 OREGONIA RD
Mailing Address - Street 2:
Mailing Address - City:OREGONIA
Mailing Address - State:OH
Mailing Address - Zip Code:45054-9737
Mailing Address - Country:US
Mailing Address - Phone:513-617-9324
Mailing Address - Fax:
Practice Address - Street 1:2825 PROGRESS WAY
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:OH
Practice Address - Zip Code:45177-7710
Practice Address - Country:US
Practice Address - Phone:937-382-5489
Practice Address - Fax:937-382-6280
Is Sole Proprietor?:No
Enumeration Date:2020-11-06
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH21192183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist