Provider Demographics
NPI:1942579404
Name:WILDING, BLAINE L (PHARMD)
Entity Type:Individual
Prefix:
First Name:BLAINE
Middle Name:L
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 1:570 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:SHELLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83274-1470
Mailing Address - Country:US
Mailing Address - Phone:208-357-0473
Mailing Address - Fax:
Practice Address - Street 1:570 S STATE ST
Practice Address - Street 2:
Practice Address - City:SHELLEY
Practice Address - State:ID
Practice Address - Zip Code:83274-1470
Practice Address - Country:US
Practice Address - Phone:208-357-0473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-29
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP4789183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist