Provider Demographics
NPI:1083872998
Name:WISWELL, DONALD BRUCE (RPH)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:BRUCE
Last Name:WISWELL
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2153 STOCKMAN CIR
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-6234
Mailing Address - Country:US
Mailing Address - Phone:916-817-2360
Mailing Address - Fax:
Practice Address - Street 1:2153 STOCKMAN CIR
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-6234
Practice Address - Country:US
Practice Address - Phone:916-817-2360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-28
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29404183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist