Healthcare Provider Details

I. General information

NPI: 1295738102
Provider Name (Legal Business Name): RUSSELL DUANE WIESLEY RPH, CDM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 09/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4343 MERLE HAY RD
DES MOINES IA
50310-1411
US

IV. Provider business mailing address

805 WALNUT RIDGE DR
WAUKEE IA
50263-9619
US

V. Phone/Fax

Practice location:
  • Phone: 515-276-4845
  • Fax: 515-331-3163
Mailing address:
  • Phone: 515-224-0227
  • Fax: 515-222-9764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number14611
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: