Provider Demographics
NPI:1790210946
Name:WISE, AMBER NICOLE (PHARMD, RPH)
Entity Type:Individual
Prefix:DR
First Name:AMBER
Middle Name:NICOLE
Last Name:WISE
Suffix:
Gender:F
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 COSHOCTON AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:OH
Mailing Address - Zip Code:43050-1975
Mailing Address - Country:US
Mailing Address - Phone:740-393-2487
Mailing Address - Fax:740-393-2745
Practice Address - Street 1:855 COSHOCTON AVE
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-1975
Practice Address - Country:US
Practice Address - Phone:740-393-2487
Practice Address - Fax:740-393-2745
Is Sole Proprietor?:No
Enumeration Date:2017-04-25
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03335093183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist