Provider Demographics
NPI:1427145481
Name:WIESMAN, BRUCE K
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:K
Last Name:WIESMAN
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 1:6205 JOHNSON ST
Mailing Address - Street 2:
Mailing Address - City:MC FARLAND
Mailing Address - State:WI
Mailing Address - Zip Code:53558-9224
Mailing Address - Country:US
Mailing Address - Phone:608-268-7273
Mailing Address - Fax:
Practice Address - Street 1:1019 RIVER ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53508-9181
Practice Address - Country:US
Practice Address - Phone:608-424-3364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8144-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist