Healthcare Provider Details

I. General information

NPI: 1932713765
Provider Name (Legal Business Name): RICHARD LEE WILGUS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2020
Last Update Date: 08/31/2020
Certification Date: 08/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 W CAMERON AVE
KELLOGG ID
83837-2359
US

IV. Provider business mailing address

131 W CAMERON AVE
KELLOGG ID
83837-2359
US

V. Phone/Fax

Practice location:
  • Phone: 208-784-6221
  • Fax: 208-786-1602
Mailing address:
  • Phone: 208-784-6221
  • Fax: 208-786-1602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP7707
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: