Provider Demographics
NPI:1861009227
Name:WISE, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WISE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2057 CHARLIE HALL BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-6164
Mailing Address - Country:US
Mailing Address - Phone:843-637-3037
Mailing Address - Fax:843-203-0883
Practice Address - Street 1:2057 CHARLIE HALL BLVD STE C
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-6164
Practice Address - Country:US
Practice Address - Phone:843-637-3037
Practice Address - Fax:843-203-0883
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12197183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist