Provider Demographics
NPI:1881214062
Name:WILDE, LINDSIE I (PHARMD)
Entity Type:Individual
Prefix:
First Name:LINDSIE
Middle Name:
Last Name:WILDE
Suffix:I
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2323 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51501-0100
Mailing Address - Country:US
Mailing Address - Phone:712-322-3111
Mailing Address - Fax:712-322-2715
Practice Address - Street 1:2323 W BROADWAY
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51501-0100
Practice Address - Country:US
Practice Address - Phone:712-322-3111
Practice Address - Fax:712-322-2715
Is Sole Proprietor?:No
Enumeration Date:2020-04-17
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR-7014183500000X
NE12963183500000X
IA20979183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist