Provider Demographics
NPI:1982093266
Name:WILDER, ELIZABETH X (R PH)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:WILDER
Suffix:X
Gender:F
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2160 STATE ROUTE 9
Mailing Address - Street 2:
Mailing Address - City:LAKE GEORGE
Mailing Address - State:NY
Mailing Address - Zip Code:12845-6120
Mailing Address - Country:US
Mailing Address - Phone:515-668-0043
Mailing Address - Fax:518-668-0051
Practice Address - Street 1:2160 STATE ROUTE 9
Practice Address - Street 2:
Practice Address - City:LAKE GEORGE
Practice Address - State:NY
Practice Address - Zip Code:12845-6120
Practice Address - Country:US
Practice Address - Phone:518-668-0043
Practice Address - Fax:518-668-0051
Is Sole Proprietor?:No
Enumeration Date:2015-01-09
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038637183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist