Provider Demographics
NPI:1992010391
Name:WILDEN, MELANIE SUE (RPH)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:SUE
Last Name:WILDEN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2360 HIGHWAY 95
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-7303
Mailing Address - Country:US
Mailing Address - Phone:928-763-5858
Mailing Address - Fax:928-763-0972
Practice Address - Street 1:2360 HIGHWAY 95
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-7303
Practice Address - Country:US
Practice Address - Phone:928-763-5858
Practice Address - Fax:928-763-0972
Is Sole Proprietor?:No
Enumeration Date:2010-08-10
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS016015183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZS016015OtherSTATE LICENSE