Provider Demographics
NPI:1356545701
Name:WILDER, THERESA LYNN (PHARMD)
Entity type:Individual
Prefix:DR
First Name:THERESA
Middle Name:LYNN
Last Name:WILDER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:729 E PARK PL
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-4774
Mailing Address - Country:US
Mailing Address - Phone:812-284-6005
Mailing Address - Fax:
Practice Address - Street 1:729 E PARK PL
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-4774
Practice Address - Country:US
Practice Address - Phone:812-284-6005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY012959183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist