Provider Demographics
NPI:1750622163
Name:WILDERMAN, TONYA JANELLE (RPH)
Entity type:Individual
Prefix:MS
First Name:TONYA
Middle Name:JANELLE
Last Name:WILDERMAN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:MR
Other - First Name:TIMOTHY
Other - Middle Name:JON
Other - Last Name:WILDERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:1400 N MCCARTHY RD
Mailing Address - Street 2:APT 2
Mailing Address - City:GRAND CHUTE
Mailing Address - State:WI
Mailing Address - Zip Code:54913
Mailing Address - Country:US
Mailing Address - Phone:414-331-7531
Mailing Address - Fax:
Practice Address - Street 1:1400 N MCCARTHY RD
Practice Address - Street 2:APT 2
Practice Address - City:GRAND CHUTE
Practice Address - State:WI
Practice Address - Zip Code:54913
Practice Address - Country:US
Practice Address - Phone:414-331-7531
Practice Address - Fax:414-463-1112
Is Sole Proprietor?:No
Enumeration Date:2013-03-10
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10979183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist