Provider Demographics
NPI:1609144419
Name:WIESER, JEFFREY S (RPH)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:S
Last Name:WIESER
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 1:292 LARWICK CIR
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46385-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5995 US HIGHWAY 6
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-4945
Practice Address - Country:US
Practice Address - Phone:219-762-2134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-07
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26019042A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist