Provider Demographics
NPI:1932451911
Name:WISTHOFF, BRUCE JAMES
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:JAMES
Last Name:WISTHOFF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 ERVIN ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075-3917
Mailing Address - Country:US
Mailing Address - Phone:615-431-2680
Mailing Address - Fax:
Practice Address - Street 1:1260 NW BROAD ST
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37129-1713
Practice Address - Country:US
Practice Address - Phone:615-890-3323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-15
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9566183500000X
IN26014178A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist