Provider Demographics
NPI:1649520099
Name:WISDOM, KATELYN ALANNA (PHARMD)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:ALANNA
Last Name:WISDOM
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 W MAIN ST STE 101
Mailing Address - Street 2:
Mailing Address - City:BATTLE GROUND
Mailing Address - State:WA
Mailing Address - Zip Code:98604-9136
Mailing Address - Country:US
Mailing Address - Phone:360-687-5133
Mailing Address - Fax:
Practice Address - Street 1:808 W MAIN ST STE 101
Practice Address - Street 2:
Practice Address - City:BATTLE GROUND
Practice Address - State:WA
Practice Address - Zip Code:98604-9136
Practice Address - Country:US
Practice Address - Phone:360-687-5133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-13
Last Update Date:2022-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0013311183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist