Organization
WILDERNS DRUG STORE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JEFFREY ALAN WILDERN RPH (PRESIDENT)
(517) 645-7680
Entity
Organization
Contact information
Practice address
123 LANSING ROAD, POTTERVILLE, MI 48876
(517) 645-7680
(517) 645-7698
Mailing address
123 LANSING ROAD, WILDERNS DRUG STORE #2, POTTERVILLE, MI 48876
(517) 645-7680
(517) 645-7698
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
Primary
5301004387
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2340444
BCBSM
MI
05
—
2340444
—
MI
Enumeration date
02/22/2006
Last updated
08/22/2020
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