Provider Demographics
NPI:1154666931
Name:THEISS, WAYNE ALBERT (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:ALBERT
Last Name:THEISS
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17960 N TAMIAMI TRL
Mailing Address - Street 2:
Mailing Address - City:NORTH FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33903-1412
Mailing Address - Country:US
Mailing Address - Phone:239-543-4244
Mailing Address - Fax:239-543-7057
Practice Address - Street 1:17960 N TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:NORTH FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33903-1412
Practice Address - Country:US
Practice Address - Phone:239-543-4244
Practice Address - Fax:239-543-7057
Is Sole Proprietor?:No
Enumeration Date:2012-12-04
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS0034369183500000X
SC10108183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist