MEDICARE: DR. AMBER NICOLE WISE PHARMD, RPH

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	03335093	OH

General Provider Information

NPI Number	:	1790210946
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AMBER NICOLE WISE PHARMD, RPH

Provider Business Mailing Address
First Line	:	855 COSHOCTON AVE
Second Line	:
City	:	MOUNT VERNON
State	:	OH
Zip	:	43050-1975
Country	:	US
Telephone Number	:	740-393-2487
Fax Number	:	740-393-2745

Provider Business Practice Location Address
First Line	:	855 COSHOCTON AVE
Second Line	:
City	:	MOUNT VERNON
State	:	OH
Zip	:	43050-1975
Country	:	US
Telephone Number	:	740-393-2487
Fax Number	:	740-393-2745

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

Provider Enumeration Date	:	04/25/2017
Last Update Date	:	04/25/2017

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