Provider Demographics
NPI:1679698666
Name:WISE, BARRY HOWARD (RPH)
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:HOWARD
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 1:13686 VAN NUYS BLVD
Mailing Address - Street 2:
Mailing Address - City:PACOIMA
Mailing Address - State:CA
Mailing Address - Zip Code:91331-3616
Mailing Address - Country:US
Mailing Address - Phone:818-896-1104
Mailing Address - Fax:818-896-7299
Practice Address - Street 1:13686 VAN NUYS BLVD
Practice Address - Street 2:
Practice Address - City:PACOIMA
Practice Address - State:CA
Practice Address - Zip Code:91331-3616
Practice Address - Country:US
Practice Address - Phone:818-896-1104
Practice Address - Fax:818-896-7299
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22779183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA327640Medicaid