Provider Demographics
NPI:1629522750
Name:WILDERMUTH, BRANDON MATTHEW (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:MATTHEW
Last Name:WILDERMUTH
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 1:2439 TREASURE ISLE DR APT 4
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33410-1359
Mailing Address - Country:US
Mailing Address - Phone:386-216-4030
Mailing Address - Fax:
Practice Address - Street 1:10720 SW VILLAGE PKWY
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34987-2188
Practice Address - Country:US
Practice Address - Phone:772-293-6153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-05
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS55262183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist