Provider Demographics
NPI:1790763068
Name:WIESE, GLEN EDWARD (R PH)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:EDWARD
Last Name:WIESE
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 N BEDELL AVE
Mailing Address - Street 2:
Mailing Address - City:DEL RIO
Mailing Address - State:TX
Mailing Address - Zip Code:78840-4111
Mailing Address - Country:US
Mailing Address - Phone:830-775-8538
Mailing Address - Fax:830-775-2797
Practice Address - Street 1:714 N BEDELL AVE
Practice Address - Street 2:
Practice Address - City:DEL RIO
Practice Address - State:TX
Practice Address - Zip Code:78840-4111
Practice Address - Country:US
Practice Address - Phone:830-775-8538
Practice Address - Fax:830-775-2797
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18036183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0410070002Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID