Healthcare Provider Details

I. General information

NPI: 1619254604
Provider Name (Legal Business Name): GREGORY BRENT WILDING PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2011
Last Update Date: 06/06/2026
Certification Date: 06/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

937 E MAIN ST
BURLEY ID
83318-2035
US

IV. Provider business mailing address

937 E MAIN ST
BURLEY ID
83318-2035
US

V. Phone/Fax

Practice location:
  • Phone: 208-678-3286
  • Fax: 801-678-1679
Mailing address:
  • Phone: 208-678-3286
  • Fax: 801-678-1679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberP9819
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP9819
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: