Provider Demographics
NPI:1164736187
Name:WISDOM, ANTHONY MICHAEL (RPH)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:MICHAEL
Last Name:WISDOM
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 1:9255 GRISSOM RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78251-2805
Mailing Address - Country:US
Mailing Address - Phone:210-680-2958
Mailing Address - Fax:210-509-0338
Practice Address - Street 1:9255 GRISSOM RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251-2805
Practice Address - Country:US
Practice Address - Phone:210-680-2958
Practice Address - Fax:210-509-0338
Is Sole Proprietor?:No
Enumeration Date:2010-08-02
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36711183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist