Provider Demographics
NPI:1942340864
Name:WISES DRUG STORE INC
Entity Type:Organization
Organization Name:WISES DRUG STORE INC
Other - Org Name:WISE'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:H
Authorized Official - Last Name:WISE
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:904-727-8362
Mailing Address - Street 1:708 SW 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32601-6427
Mailing Address - Country:US
Mailing Address - Phone:352-376-8286
Mailing Address - Fax:352-375-8686
Practice Address - Street 1:708 SW 4TH AVE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32601-6427
Practice Address - Country:US
Practice Address - Phone:352-376-8286
Practice Address - Fax:352-374-3799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH3743336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL673317498Medicaid
FL103626200Medicaid