Provider Demographics
NPI:1124617683
Name:WISENER, RICHARD WESLEY
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:WESLEY
Last Name:WISENER
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 1:104 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:75949-8620
Mailing Address - Country:US
Mailing Address - Phone:936-876-5159
Mailing Address - Fax:936-422-4821
Practice Address - Street 1:104 N MAIN ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:TX
Practice Address - Zip Code:75949-8620
Practice Address - Country:US
Practice Address - Phone:936-876-5159
Practice Address - Fax:936-422-4821
Is Sole Proprietor?:No
Enumeration Date:2021-01-11
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24898183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist