Provider Demographics
NPI:1871574681
Name:WISDO, THOMAS M (RPH)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:M
Last Name:WISDO
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 WALKER DR
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:DE
Mailing Address - Zip Code:19720-4682
Mailing Address - Country:US
Mailing Address - Phone:302-832-8282
Mailing Address - Fax:
Practice Address - Street 1:3400 EDGMONT AVE
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:PA
Practice Address - Zip Code:19015-2804
Practice Address - Country:US
Practice Address - Phone:610-872-5418
Practice Address - Fax:610-872-1969
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP039916L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARP039916LOtherSTATE LICENSE
KY015194OtherPHARMACIST LICENSE