Provider Demographics
NPI:1154984672
Name:WISE, CARMEN
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:
Last Name:WISE
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 1:11373 CORTEZ BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34613-5411
Mailing Address - Country:US
Mailing Address - Phone:352-600-7838
Mailing Address - Fax:
Practice Address - Street 1:11373 CORTEZ BLVD STE 101
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-5411
Practice Address - Country:US
Practice Address - Phone:352-600-7838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-19
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS38253183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty