Provider Demographics
NPI:1811260342
Name:WISE, BENJAMIN (PHARMD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:WISE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 3RD ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-1969
Mailing Address - Country:US
Mailing Address - Phone:509-758-8230
Mailing Address - Fax:509-758-8484
Practice Address - Street 1:511 3RD ST
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-1969
Practice Address - Country:US
Practice Address - Phone:509-758-8230
Practice Address - Fax:509-758-8484
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-14
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH 60023724183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPH 60023724OtherSTATE PHARMACIST LICENSE