Provider Demographics
NPI:1639419476
Name:WILDER, DANIEL TROY (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:TROY
Last Name:WILDER
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 1:2050 NORTHDALE BLVD NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-3036
Mailing Address - Country:US
Mailing Address - Phone:763-754-9036
Mailing Address - Fax:763-754-0867
Practice Address - Street 1:2050 NORTHDALE BLVD NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-3036
Practice Address - Country:US
Practice Address - Phone:763-754-9036
Practice Address - Fax:763-754-0867
Is Sole Proprietor?:No
Enumeration Date:2013-02-14
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN120919183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist