Provider Demographics
NPI:1932713765
Name:WILGUS, RICHARD LEE
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:LEE
Last Name:WILGUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 W CAMERON AVE
Mailing Address - Street 2:
Mailing Address - City:KELLOGG
Mailing Address - State:ID
Mailing Address - Zip Code:83837-2359
Mailing Address - Country:US
Mailing Address - Phone:208-784-6221
Mailing Address - Fax:208-786-1602
Practice Address - Street 1:131 W CAMERON AVE
Practice Address - Street 2:
Practice Address - City:KELLOGG
Practice Address - State:ID
Practice Address - Zip Code:83837-2359
Practice Address - Country:US
Practice Address - Phone:208-784-6221
Practice Address - Fax:208-786-1602
Is Sole Proprietor?:No
Enumeration Date:2020-08-31
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP7707183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist