Healthcare Provider Details

I. General information

NPI: 1750622163
Provider Name (Legal Business Name): TONYA JANELLE WILDERMAN RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TIMOTHY JON WILDERMAN RPH

II. Dates (important events)

Enumeration Date: 03/10/2013
Last Update Date: 10/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 N MCCARTHY RD APT 2
GRAND CHUTE WI
54913
US

IV. Provider business mailing address

1400 N MCCARTHY RD APT 2
GRAND CHUTE WI
54913
US

V. Phone/Fax

Practice location:
  • Phone: 414-331-7531
  • Fax: 414-463-1112
Mailing address:
  • Phone: 414-331-7531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number10979
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: