Provider Demographics
NPI:1619254604
Name:WILDING, GREGORY BRENT (PHARMD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:BRENT
Last Name:WILDING
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 1:420 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84663-2251
Mailing Address - Country:US
Mailing Address - Phone:801-853-1214
Mailing Address - Fax:801-853-1217
Practice Address - Street 1:420 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGVILLE
Practice Address - State:UT
Practice Address - Zip Code:84663-2251
Practice Address - Country:US
Practice Address - Phone:801-853-1214
Practice Address - Fax:801-853-1217
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-04
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6715977-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist