Provider Demographics
NPI:1013271501
Name:WISINSKI, THOMAS JOSEPH (RPH)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:JOSEPH
Last Name:WISINSKI
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 N EDWARDS BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-4595
Mailing Address - Country:US
Mailing Address - Phone:262-248-5610
Mailing Address - Fax:262-248-5611
Practice Address - Street 1:660 N EDWARDS BLVD
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-4595
Practice Address - Country:US
Practice Address - Phone:262-248-5610
Practice Address - Fax:262-248-5611
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-28
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16629-40183500000X
IL051036213183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist