Healthcare Provider Details

I. General information

NPI: 1538445705
Provider Name (Legal Business Name): JAMIE WYSE RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2011
Last Update Date: 11/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6495 OLD TROY PIKE
HUBER HEIGHTS OH
45424-3648
US

IV. Provider business mailing address

6530 STILLCREST WAY
DAYTON OH
45414-5908
US

V. Phone/Fax

Practice location:
  • Phone: 937-236-6054
  • Fax:
Mailing address:
  • Phone: 937-898-5160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03126070
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number1999140343
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: