Healthcare Provider Details

I. General information

NPI: 1457468340
Provider Name (Legal Business Name): PATRICIA MELONEE WISE R.PH.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 08/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E WOODROW WILSON AVE 119A
JACKSON MS
39216-5116
US

IV. Provider business mailing address

1500 E. WOODBOUL WILSON 119A
JACKSON MS
39216-5116
US

V. Phone/Fax

Practice location:
  • Phone: 601-364-1555
  • Fax:
Mailing address:
  • Phone: 601-364-1555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberE6339
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberE-6339
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: