Healthcare Provider Details

I. General information

NPI: 1427145481
Provider Name (Legal Business Name): BRUCE K WIESMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1019 RIVER ST
BELLEVILLE WI
53508-9181
US

IV. Provider business mailing address

6205 JOHNSON ST
MC FARLAND WI
53558-9224
US

V. Phone/Fax

Practice location:
  • Phone: 608-424-3364
  • Fax:
Mailing address:
  • Phone: 608-268-7273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number8144-040
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: