Provider Demographics
NPI:1770606162
Name:WISE, REBECCA MILLER (RPH, PHARMD, MED)
Entity type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:MILLER
Last Name:WISE
Suffix:
Gender:F
Credentials:RPH, PHARMD, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1858 W GRANDVIEW BLVD
Mailing Address - Street 2:BAYFRONT CAMPUS - LECOM MTM SERVICES
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16509-1025
Mailing Address - Country:US
Mailing Address - Phone:814-868-2584
Mailing Address - Fax:814-868-2589
Practice Address - Street 1:1858 W GRANDVIEW BLVD
Practice Address - Street 2:BAYFRONT CAMPUS - LECOM MTM SERVICES
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16509-1025
Practice Address - Country:US
Practice Address - Phone:814-868-2584
Practice Address - Fax:814-868-2589
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP440472183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1760736870OtherLECOM MTM SERVICES NPI