Provider Demographics
NPI:1225072093
Name:WISDOM DRUG LLC
Entity Type:Organization
Organization Name:WISDOM DRUG LLC
Other - Org Name:VANDIVORT DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:TEEL
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:WISDOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-729-4114
Mailing Address - Street 1:117 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MO
Mailing Address - Zip Code:65560-1255
Mailing Address - Country:US
Mailing Address - Phone:573-729-4114
Mailing Address - Fax:573-729-5353
Practice Address - Street 1:117 W 4TH ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MO
Practice Address - Zip Code:65560-1255
Practice Address - Country:US
Practice Address - Phone:573-729-4114
Practice Address - Fax:573-729-5353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOPS 0048553336C0003X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600126916Medicaid