Provider Demographics
NPI:1407141096
Name:WISE, JASON (PHARMD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:WISE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3146 ELMIRA CT
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80238-2929
Mailing Address - Country:US
Mailing Address - Phone:303-981-8798
Mailing Address - Fax:
Practice Address - Street 1:7930 NORTHFIELD BLVD
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80238-3527
Practice Address - Country:US
Practice Address - Phone:303-209-8721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-13
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO16028183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO16028OtherCO STATE LICENSE NUMBER