Provider Demographics
NPI:1386972313
Name:WILDERN DURABLE SUPPLIES LLC
Entity type:Organization
Organization Name:WILDERN DURABLE SUPPLIES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:LARSON
Authorized Official - Last Name:WILDERN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:517-543-0978
Mailing Address - Street 1:201 S COCHRAN AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48813-1550
Mailing Address - Country:US
Mailing Address - Phone:517-543-0978
Mailing Address - Fax:517-541-1548
Practice Address - Street 1:201 S COCHRAN AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:MI
Practice Address - Zip Code:48813-1550
Practice Address - Country:US
Practice Address - Phone:517-543-0978
Practice Address - Fax:517-541-1548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-02
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6296310001Medicare NSC
MI6296310001Medicare PIN