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General NPI Number Information
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NPI Number | 1295230308
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Entity Type | Individual
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Provider Name | MICHAEL E WISE RPH
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Gender | Male
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Dates
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Enumeration Date | 03/29/2018
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Last Update Date | 03/29/2018
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Provider Practice Location Address
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Address Line | 9650 W 131ST ST
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City | PALOS PARK
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State | IL
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Zip | 60464-1640
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Country | US
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Telephone | 708-361-8094
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Fax |
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Provider Business Mailing Address
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Address Line | 12251 S 80TH AVE
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City | PALOS HEIGHTS
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State | IL
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Zip | 60463-1256
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Country | US
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Telephone | 708-923-4122
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 051.030136
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License Number State | IL
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