Healthcare Provider Details

I. General information

NPI: 1548544422
Provider Name (Legal Business Name): MARK EDWARD WIENKE R.PH., CGP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2011
Last Update Date: 10/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4112 FALL RIDGE DR
COLUMBIA MO
65203-6629
US

IV. Provider business mailing address

4112 FALL RIDGE DR
COLUMBIA MO
65203-6629
US

V. Phone/Fax

Practice location:
  • Phone: 573-446-0616
  • Fax:
Mailing address:
  • Phone: 573-446-0616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number041282
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number041282
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: