Provider Demographics
NPI:1841848942
Name:WISER, STACEY ANN
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:ANN
Last Name:WISER
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 1:7935 S EMERSON AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-8555
Mailing Address - Country:US
Mailing Address - Phone:317-865-7593
Mailing Address - Fax:317-865-1597
Practice Address - Street 1:7935 S EMERSON AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-8555
Practice Address - Country:US
Practice Address - Phone:317-865-7593
Practice Address - Fax:317-865-1597
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-01
Last Update Date:2019-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26024557A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist