Provider Demographics
NPI:1396865416
Name:WIESE, LANCE EDWARD (RPH)
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:EDWARD
Last Name:WIESE
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 1:1429 ROBY RD
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:WI
Mailing Address - Zip Code:53589-1270
Mailing Address - Country:US
Mailing Address - Phone:608-873-8641
Mailing Address - Fax:
Practice Address - Street 1:711 N MAIN ST
Practice Address - Street 2:
Practice Address - City:EDGERTON
Practice Address - State:WI
Practice Address - Zip Code:53534-1530
Practice Address - Country:US
Practice Address - Phone:608-884-3308
Practice Address - Fax:608-884-7725
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8529-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist