Provider Demographics
NPI:1104569268
Name:WILDER, DANIEL (CPHT)
Entity type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:
Last Name:WILDER
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 PEORIA ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61571-2487
Mailing Address - Country:US
Mailing Address - Phone:309-444-1681
Mailing Address - Fax:
Practice Address - Street 1:300 N MAIN ST
Practice Address - Street 2:
Practice Address - City:EAST PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61611-2081
Practice Address - Country:US
Practice Address - Phone:309-694-7661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-18
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL049.278851183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician