Provider Demographics
NPI:1063387686
Name:WISE WELL SUPPLIES INC
Entity type:Organization
Organization Name:WISE WELL SUPPLIES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMANUDDIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MOHAMMAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-465-4301
Mailing Address - Street 1:418 N MAIN ST FL 2
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-1813
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:418 N MAIN ST FL 2
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-1813
Practice Address - Country:US
Practice Address - Phone:313-465-4301
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-10-06
Last Update Date:2025-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory