Provider Demographics
NPI:1134791130
Name:WISE, KAYLA RUTH
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:RUTH
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 1:2914 CHANDLER AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97403-2232
Mailing Address - Country:US
Mailing Address - Phone:541-255-7763
Mailing Address - Fax:
Practice Address - Street 1:2130 MARCOLA RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-2592
Practice Address - Country:US
Practice Address - Phone:541-747-3362
Practice Address - Fax:541-741-2287
Is Sole Proprietor?:No
Enumeration Date:2021-07-11
Last Update Date:2021-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORCPT-0012209183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician