Provider Demographics
NPI:1942956271
Name:WILDERMUTH, AMY DEE (RPH)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:DEE
Last Name:WILDERMUTH
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:DEE
Other - Last Name:CUTTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:1575 LYONS RD
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45458-1881
Mailing Address - Country:US
Mailing Address - Phone:937-439-9779
Mailing Address - Fax:937-439-5443
Practice Address - Street 1:1575 LYONS RD
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45458-1881
Practice Address - Country:US
Practice Address - Phone:937-439-9779
Practice Address - Fax:937-439-5443
Is Sole Proprietor?:No
Enumeration Date:2022-02-24
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY011515183500000X
OH030122458183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist