Healthcare Provider Details

I. General information

NPI: 1659503084
Provider Name (Legal Business Name): DAVID S WILDES JR. PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2009
Last Update Date: 08/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8400 MONTGOMERY BLVD NE
ALBUQUERQUE NM
87111-2302
US

IV. Provider business mailing address

8400 MONTGOMERY BLVD NE
ALBUQUERQUE NM
87111-2302
US

V. Phone/Fax

Practice location:
  • Phone: 505-559-9134
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00007133
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: