Provider Demographics
NPI:1336421940
Name:WILDER, MARIE CATHERINE (DPH)
Entity Type:Individual
Prefix:MRS
First Name:MARIE
Middle Name:CATHERINE
Last Name:WILDER
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2120 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICKASHA
Mailing Address - State:OK
Mailing Address - Zip Code:73018-6810
Mailing Address - Country:US
Mailing Address - Phone:405-222-0278
Mailing Address - Fax:405-222-0693
Practice Address - Street 1:2120 S 4TH ST
Practice Address - Street 2:
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018-6810
Practice Address - Country:US
Practice Address - Phone:405-222-0278
Practice Address - Fax:405-222-0693
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-09
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11285183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist