Provider Demographics
NPI:1407397524
Name:WISDOM PHARMACY,LLC
Entity type:Organization
Organization Name:WISDOM PHARMACY,LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MICHAEIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-252-4455
Mailing Address - Street 1:4123 W HILLSBOROUGH AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614
Mailing Address - Country:US
Mailing Address - Phone:727-935-7039
Mailing Address - Fax:727-935-1032
Practice Address - Street 1:4123 W HILLSBOROUGH AVE
Practice Address - Street 2:SUITE C
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614
Practice Address - Country:US
Practice Address - Phone:727-935-7039
Practice Address - Fax:727-935-1032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-09
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH306623336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021210700Medicaid
2170446OtherPK