Provider Demographics
NPI:1831626530
Name:WISA, RANDA
Entity type:Individual
Prefix:
First Name:RANDA
Middle Name:
Last Name:WISA
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 1:1004 COMMONS DR
Mailing Address - Street 2:
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816-5217
Mailing Address - Country:US
Mailing Address - Phone:732-485-9570
Mailing Address - Fax:
Practice Address - Street 1:1004 COMMONS DR
Practice Address - Street 2:
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816-5217
Practice Address - Country:US
Practice Address - Phone:732-485-9570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-12
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RJ06843183500000X
NJ28RI03792000183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist