Provider Demographics
NPI:1548544422
Name:WIENKE, MARK EDWARD (RPH, CGP)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:EDWARD
Last Name:WIENKE
Suffix:
Gender:M
Credentials:RPH, CGP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4112 FALL RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-6629
Mailing Address - Country:US
Mailing Address - Phone:573-446-0616
Mailing Address - Fax:
Practice Address - Street 1:4112 FALL RIDGE DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-6629
Practice Address - Country:US
Practice Address - Phone:573-446-0616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-10
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO041282183500000X, 1835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835G0303XPharmacy Service ProvidersPharmacistGeriatric
No183500000XPharmacy Service ProvidersPharmacist