Provider Demographics
NPI:1881669745
Name:WILDERNS DRUG STORE
Entity Type:Organization
Organization Name:WILDERNS DRUG STORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:WILDERN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:517-645-7680
Mailing Address - Street 1:123 LANSING ROAD
Mailing Address - Street 2:WILDERNS DRUG STORE #2
Mailing Address - City:POTTERVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48876
Mailing Address - Country:US
Mailing Address - Phone:517-645-7680
Mailing Address - Fax:517-645-7698
Practice Address - Street 1:123 LANSING ROAD
Practice Address - Street 2:
Practice Address - City:POTTERVILLE
Practice Address - State:MI
Practice Address - Zip Code:48876
Practice Address - Country:US
Practice Address - Phone:517-645-7680
Practice Address - Fax:517-645-7698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301004387333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2340444OtherBCBSM
MI2340444Medicaid
MI2340444OtherBCBSM