Provider Demographics
NPI:1568435873
Name:WILDERNS DRUG STORE
Entity Type:Organization
Organization Name:WILDERNS DRUG STORE
Other - Org Name:WILDERNS DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILDERN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-543-0978
Mailing Address - Street 1:201 S COCHRAN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48813
Mailing Address - Country:US
Mailing Address - Phone:517-543-0978
Mailing Address - Fax:517-541-1548
Practice Address - Street 1:201 S COCHRAN AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:MI
Practice Address - Zip Code:48813-1550
Practice Address - Country:US
Practice Address - Phone:517-432-0830
Practice Address - Fax:517-543-9087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-08
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI530100084332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI540B305019OtherBCBSM
MI2520171Medicaid
MI0140800001Medicare NSC
MI2520171Medicaid