Provider Demographics
NPI:1942600499
Name:WISHERD, BRYAN (RPH PHARMD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:WISHERD
Suffix:
Gender:M
Credentials:RPH PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 MASSACHUSETTS AVE
Mailing Address - Street 2:
Mailing Address - City:BUTTE
Mailing Address - State:MT
Mailing Address - Zip Code:59701-6019
Mailing Address - Country:US
Mailing Address - Phone:406-494-3754
Mailing Address - Fax:406-494-3823
Practice Address - Street 1:2500 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-6019
Practice Address - Country:US
Practice Address - Phone:406-494-3754
Practice Address - Fax:406-494-3823
Is Sole Proprietor?:No
Enumeration Date:2014-09-02
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT25538183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist