Provider Demographics
NPI:1962770701
Name:WILDER, TAMEKO
Entity type:Individual
Prefix:
First Name:TAMEKO
Middle Name:
Last Name:WILDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 PRESTWICK LN
Mailing Address - Street 2:UNIT 505
Mailing Address - City:WHEELING
Mailing Address - State:IL
Mailing Address - Zip Code:60090-6247
Mailing Address - Country:US
Mailing Address - Phone:312-375-7107
Mailing Address - Fax:
Practice Address - Street 1:720 PRESTWICK LN
Practice Address - Street 2:UNIT 505
Practice Address - City:WHEELING
Practice Address - State:IL
Practice Address - Zip Code:60090-6247
Practice Address - Country:US
Practice Address - Phone:312-375-7107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-08
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051290390183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist