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General NPI Number Information
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NPI Number | 1396865416
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Entity Type | Individual
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Provider Name | LANCE EDWARD WIESE RPH
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Gender | Male
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Dates
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Enumeration Date | 03/30/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 711 N MAIN ST
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City | EDGERTON
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State | WI
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Zip | 53534-1530
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Country | US
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Telephone | 608-884-3308
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Fax | 608-884-7725
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Provider Business Mailing Address
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Address Line | 1429 ROBY RD
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City | STOUGHTON
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State | WI
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Zip | 53589-1270
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Country | US
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Telephone | 608-873-8641
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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 | 8529-040
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License Number State | WI
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