MEDICARE: RUSSELL DUANE WIESLEY RPH, CDM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	14611	IA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1295738102
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUSSELL DUANE WIESLEY RPH, CDM

Provider Business Mailing Address
First Line	:	805 WALNUT RIDGE DR
Second Line	:
City	:	WAUKEE
State	:	IA
Zip	:	50263-9619
Country	:	US
Telephone Number	:	515-224-0227
Fax Number	:	515-222-9764

Provider Business Practice Location Address
First Line	:	4343 MERLE HAY RD
Second Line	:
City	:	DES MOINES
State	:	IA
Zip	:	50310-1411
Country	:	US
Telephone Number	:	515-276-4845
Fax Number	:	515-331-3163

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	09/18/2008

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