MEDICARE: STEPHEN WISE R.PH

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	RP043577R	PA

General Provider Information

NPI Number	:	1558414110
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHEN WISE R.PH

Provider Business Mailing Address
First Line	:	135 S 19TH ST
Second Line	:	APT. 903
City	:	PHILADELPHIA
State	:	PA
Zip	:	19103-4912
Country	:	US
Telephone Number	:	215-563-6663
Fax Number	:

Provider Business Practice Location Address
First Line	:	135 S 19TH ST
Second Line	:	APT. 903
City	:	PHILADELPHIA
State	:	PA
Zip	:	19103-4912
Country	:	US
Telephone Number	:	215-563-6663
Fax Number	:

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

Provider Enumeration Date	:	01/18/2007
Last Update Date	:	07/08/2007

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