Healthcare Provider Details

I. General information

NPI: 1902393705
Provider Name (Legal Business Name): KELLY WISE PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2018
Last Update Date: 04/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 CHILDRENS DR
COLUMBUS OH
43205-2664
US

IV. Provider business mailing address

263 SHELDON AVE
COLUMBUS OH
43207-1254
US

V. Phone/Fax

Practice location:
  • Phone: 614-722-2879
  • Fax:
Mailing address:
  • Phone: 419-618-3371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number03334421
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: