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General NPI Number Information
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NPI Number | 1891990131
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Entity Type | Individual
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Provider Name | GARY MARK WISE RPH
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Gender | Male
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Dates
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Enumeration Date | 06/18/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 470 SAFFORD AVE W
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City | THOMASVILLE
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State | AL
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Zip | 36784-3112
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Country | US
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Telephone | 334-636-9809
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Fax | 334-636-9807
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Provider Business Mailing Address
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Address Line | 470 SAFFORD AVE W
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City | THOMASVILLE
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State | AL
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Zip | 36784-3112
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Country | US
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Telephone | 334-636-9809
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Fax | 334-636-9807
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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 | 9084
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License Number State | AL
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