1336262922 NPI number — MR. EDGAR H. WISE III RPH

Table of content: STEVEN RILEY (NPI 1669855508)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336262922 NPI number — MR. EDGAR H. WISE III RPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WISE
Provider First Name:
EDGAR
Provider Middle Name:
H.
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
III
Provider Credential Text:
RPH
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336262922
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2715 NW 22ND TER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GAINESVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32605-2968
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-378-7585
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
239 W UNIVERSITY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GAINESVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32601-5211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-372-4371
Provider Business Practice Location Address Fax Number:
352-375-8686
Provider Enumeration Date:
04/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  PS 12201 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PS 12201 . This is a "PHARMACIST LICENSE NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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