Provider Demographics
NPI:1558414110
Name:WISE, STEPHEN (RPH)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:WISE
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 1:135 S 19TH ST
Mailing Address - Street 2:APT. 903
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-4912
Mailing Address - Country:US
Mailing Address - Phone:215-563-6663
Mailing Address - Fax:
Practice Address - Street 1:135 S 19TH ST
Practice Address - Street 2:APT. 903
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-4912
Practice Address - Country:US
Practice Address - Phone:215-563-6663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP043577R183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist