Provider Demographics
NPI:1255931036
Name:WILD, REGAN Z
Entity type:Individual
Prefix:
First Name:REGAN
Middle Name:Z
Last Name:WILD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 SAM HOUSTON JONES PKWY
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70611-5603
Mailing Address - Country:US
Mailing Address - Phone:337-214-6402
Mailing Address - Fax:
Practice Address - Street 1:260 SAM HOUSTON JONES PKWY
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70611-5603
Practice Address - Country:US
Practice Address - Phone:337-214-6402
Practice Address - Fax:337-214-6403
Is Sole Proprietor?:No
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.023519183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist