Provider Demographics
NPI:1144850140
Name:WISDOM, CAROL P
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:P
Last Name:WISDOM
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 1:9319 ARCH STREET PL
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-5527
Mailing Address - Country:US
Mailing Address - Phone:256-461-8530
Mailing Address - Fax:
Practice Address - Street 1:4579 WALL TRIANA HWY
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-9305
Practice Address - Country:US
Practice Address - Phone:256-461-8530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-19
Last Update Date:2020-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL111261835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist