MEDICARE: DENISE WISELY REGISTER PHARMACIST

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	051039362	IL

General Provider Information

NPI Number	:	1336691120
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DENISE WISELY REGISTER PHARMACIST

Provider Business Mailing Address
First Line	:	4260 POLK RD
Second Line	:
City	:	OAKDALE
State	:	IL
Zip	:	62268-2104
Country	:	US
Telephone Number	:	618-806-1567
Fax Number	:

Provider Business Practice Location Address
First Line	:	4260 POLK RD
Second Line	:
City	:	OAKDALE
State	:	IL
Zip	:	62268-2104
Country	:	US
Telephone Number	:	618-806-1567
Fax Number	:

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

Provider Enumeration Date	:	10/27/2016
Last Update Date	:	10/27/2016

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