Provider Demographics
NPI:1578165411
Name:WIESE, MEGAN MARIE (RPH)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:MARIE
Last Name:WIESE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 N LINDEN ST
Mailing Address - Street 2:
Mailing Address - City:WAHOO
Mailing Address - State:NE
Mailing Address - Zip Code:68066-1961
Mailing Address - Country:US
Mailing Address - Phone:402-443-4167
Mailing Address - Fax:
Practice Address - Street 1:526 N LINDEN ST
Practice Address - Street 2:
Practice Address - City:WAHOO
Practice Address - State:NE
Practice Address - Zip Code:68066-1961
Practice Address - Country:US
Practice Address - Phone:402-443-4167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE13140183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist