MEDICARE: MR. THOMAS M WISDO RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	RP039916L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	RP039916L	OTHER	PA	STATE LICENSE
2	015194	OTHER	KY	PHARMACIST LICENSE

General Provider Information

NPI Number	:	1871574681
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. THOMAS M WISDO RPH

Provider Business Mailing Address
First Line	:	14 WALKER DR
Second Line	:
City	:	NEW CASTLE
State	:	DE
Zip	:	19720-4682
Country	:	US
Telephone Number	:	302-832-8282
Fax Number	:

Provider Business Practice Location Address
First Line	:	3400 EDGMONT AVE
Second Line	:
City	:	BROOKHAVEN
State	:	PA
Zip	:	19015-2804
Country	:	US
Telephone Number	:	610-872-5418
Fax Number	:	610-872-1969

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/09/2005
Last Update Date	:	08/31/2010

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