=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154984672
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARMEN WISE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2019
-----------------------------------------------------
Last Update Date | 06/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11373 CORTEZ BLVD STE 101
-----------------------------------------------------
City | BROOKSVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34613-5411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-600-7838
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11373 CORTEZ BLVD STE 101
-----------------------------------------------------
City | BROOKSVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34613-5411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-600-7838
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | PS38253
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------